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HomeMy WebLinkAbout2015-0602 Council Agenda PACKET CITY OF ASHLAND Important: Any citizen may orally address the Council on non-agenda items during the Public Forum- Any citizen may submit written comments to the Council on any item on the Agenda, unless it is the subject of a public hearing and the record is closed. Time pennitting, the Presiding Officer may allow oral testimony. If you wish to speak, please fill out the Speaker Request form located near the entrance to the Council Chambers. The chair will recognize you and inform you as to the amount of time allotted to you, if any. The time granted will be dependent to some extent on the nature of the item under discussion, the number of people who wish to speak, and the length of the agenda. AGENDA FOR THE REGULAR MEETING ASHLAND CITY COUNCIL June 2, 2015 Council Chambers 1175 E. Main Street Note: Items on the Agenda not considered due to time constraints are automatically continued to the next regularly scheduled Council meeting [AMC 2.04.030.E.] 7:00 p.m. Regular Meeting L CALL TO ORDER - II. PLEDGE OF ALLEGIANCE Ill. ROLL CALL IV. MAYOR'S ANNOUNCEMENTS V. APPROVAL OF MINUTES 1. Executive Session of May 18, 2015 2. Business Meeting of May 19, 2015 VI. SPECIAL PRESENTATIONS & AWARDS 1. Annual presentation by the Band Board 2. Update regarding the 2015 Drought 3. Proclamation of June 14, 2015, as Flag Day VII. PUBLIC FORUM Business from the audience not included on the agenda. (Total time allowed for Public Forum is 15 minutes. The Mayor will set time limits to enable all people wishing to speak to complete their testimony.) [15 minutes maximum] VIII. CONSENT AGENDA 1. Liquor license application for Duke Taffy dba Southern Oregon Growlers, LLC 2. Appointment of Roger Pearce to the Planning Commission 3. Jackson County supervising physician support agreement 4. Declaration and authorization to dispose of surplus property in a sealed bid - auction 5. Mayoral appointment of Rich Rosenthal as Council liaison to the Amigo Club COUNCIL MEETINGS ARE BROADCAST LIVE ON CHANNEL 9. STARTING APRIL 15, 2014, CHARTER CABLE WILL BROADCAST LIVE ON CHANNEL 180. VISIT THE CITY OF ASHLAND'S WEB SITE AT WWW.ASHLAND.OR.US IX. PUBLIC HEARINGS (Persons wishing to speak are to submit a "speaker request form" prior to the commencement of the public hearing. Public hearings shall conclude at 9:00 p.m. and be continued to a future date to be set by the Council, unless the Council, by a two-thirds vote of those present, extends the hearing(s) until up to 10:30 p.m. at which time the Council shall set a date for continuance and shall proceed with the balance of the agenda.) None X. UNFINISHED BUSINESS None XI. NEW AND MISCELLANEOUS BUSINESS 1. Confirmation of Mayoral appointment of Tighe O'Meara as Police Chief 2. Adoption of the City's self-insured health plan for the plan year July 1, 2015 through June 30, 2016 3. Community Climate and Energy Action Plan ad hoc Committee formation . request XII. ORDINANCES, RESOLUTIONS AND CONTRACTS 1. Approval of a resolution titled, "A resolution approving the jurisdictional transfer of Peachy Road" 2. Second reading by title only of an ordinance titled, "An ordinance amending Chapter 11.28 to authorize City Council to establish presumptive parking violation fines by resolution" XIII. OTHER BUSINESS FROM COUNCIL MEMBERS/REPORTS FROM COUNCIL LIAISONS XIV. ADJOURNMENT OF BUSINESS MEETING In compliance with the Americans with Disabilities Act, if you need special assistance to participate in this meeting, please contact the City Administrator's office at (541) 488-6002 (TTY phone number 1-800-735-2900). Notification 72 hours prior to the meeting will enable the City to make reasonable arrangements to ensure accessibility to the meeting (28 CFR 35.102-35.104 ADA Title I). COUNCIL MEETINGS ARE BROADCAST LIVE ON CHANNEL 9. STARTING APRIL 15, 2014, CHARTER CABLE WILL BROADCAST LIVE ON CHANNEL 180. VISIT THE CITY OF ASHLAND'S WEB SITE AT WWW.ASHLAND.OR.US Ashland City Council Meeting May 19, 2015 Page 1 of 8 MINUTES FOR THE REGULAR MEETING ASHLAND CITY COUNCIL May 19, 2015 Council Chambers 1175 E. Main Street CALL TO ORDER Mayor Stromberg called the meeting to order at 7:00 p.m. in the Civic Center Council Chambers. ROLL CALL Councilor Voisin, Morris, Lemhouse, Seftinger, Rosenthal, and Marsh were present. MAYOR'S ANNOUNCEMENTS Mayor Stromberg announced the City completed the annual appointment process for the various Commissions, Committees, and Boards but there were still vacancies on the following Commissions: Airport, Forest Lands, Housing & Human Services, Public Arts, Transportation, Tree, and Wildfire Mitigation. He added an agenda item under NEW AND MISCELLANEOUS BUSINESS regarding a letter to the United States Forest Service on summer activities proposed by Mt. Ashland Association. Mayor Stromberg went on to announce his intention to appoint Tighe O'Meara as Ashland's next Chief of Police and seek Council confirmation at the June 2, 2015 Council meeting. APPROVAL OF MINUTES The minutes of the Study Session of May 4, 2015 and Business Meeting of May 5, 2015 were approved as presented. SPECIAL PRESENTATIONS & AWARDS 1. Annual presentation by Michael Cavallaro of RVCOG Michael Cavallaro of the Rogue Valley Council of Governments (RVCOG) provided the annual report and submitted the Program and Financial Update for January 2015 into the record. He highlighted programs and resources RVCOG provided throughout the valley. RVCOG developed the first certification program in the United States that facilitated and promoted the incorporation of features in residences that allowed people to age safely at home. The Metropolitan Planning Organization (MPO) was a federally designated transportation planning area. Whenever population rose above 50,000, the federal government designated an area based on population density and created an MPO. The involved jurisdictions worked with professional staff and facilitated decision making that complimented the growth of the region. 2. Annual presentation by the Wildfire Mitigation Commission Forestry Division Chief Chris Chambers introduced Steve Parks the coordinator for the Fire Adapted Communities and Victoria Sturtevant chair of the Wildfire Mitigation Commission. Mr. Parks explained Firewise currently had 22 communities. They hosted a community clean up in April with 152 individual loads of green debris dropped off at the Valley View Transfer Station for a total of 200 cubic yards of debris. He submitted Guidelines for Firewise Construction into the record that complimented the Firewise Landscaping documents published a few years prior. Division Chief Chambers provided background on the Community Wildfire Protection Plan (CWPP) and the upcoming update to incorporate three main tenants of the National Cohesive Wildland Fire Management Strategy (The Cohesive Strategy) which were the Fire Adapted Communities, resilient landscapes, and appropriate fire suppression and response. Ashland was one of eleven pilot communities nationwide implementing The Cohesive Strategy. Chair Sturtevant further explained the CWPP update would involve a Ashland City Council Meeting May 19, 2015 Page 2 of 8 series of meetings with the community and businesses followed with a document that listed strategic actions people could take to lower fire risk. PUBLIC FORUM Kristina Lefever/2359 Blue Sky Lane/Spoke regarding the Freemont Cottonwood tree on Clay Street. Cottonwood trees were one of the best sources of resin and nectar for honeybees. Honeybees were under siege from a variety of viruses and diseases and declining at an alarming rate. She quoted from a document submitted into the record. The Fremont Cottonwood tree was old and an important source of resin and because of that, propolis. She questioned if there were a way to retain the tree, house people, and give bees a chance and offered pollinator friendly alternatives. Rael Reif/125 N Third Street/Requested Council to consider banning the use of Roundup citywide. The World Health Organization and the American Cancer Society both stated the Glyphosate found in Roundup was a carcinogen. She submitted documents into the record. The City of Los Angeles was suing Monsanto for false advertising. She volunteered her services for alternatives to using Roundup on weeds. Joseph Kauth/1 Corral Lane/Spoke on science and temporal soil building. Removing the process of temporal soil building from an area that was geologically sensitive in conjunction with removing 20,000 acres of old growth endangered habitat for many species. It was like pouring gasoline on a fire. CONSENT AGENDA 1. Approval of minutes from boards, commissions, and committees 2. Approval of a public contract for banking services 3. Approval of recommendations from the Public Art Commission for painting electric utility boxes near the recycling area at North Mountain Park 4. Approval of an intergovernmental agreement between Jackson County and the City of Ashland for sobering unit services 5. 2015 Annual Appointments - Tree Commission 6. Amendment to the intergovernmental agreement with Jackson County to lease the Ashland Library to the Jackson County Library District 7. Endorsement of Southern Oregon Birth Connections Fall Family Fair for the purpose of hanging a banner Councilor Rosenthal/Lemhouse m/s to approve Consent Agenda items. Voice Vote: all AYES. Motion passed. PUBLIC HEARINGS 1. Public Hearing and approval of a resolution titled, "A resolution adopting a miscellaneous fees and charges document and repealing prior fee resolutions 2014-07 and 2014-09" Administrative Services Director Lee Tuneberg explained this year Airport fees and charges were incorporated into the Miscellaneous Fees and Charges document instead of changing those fees through a separate resolution. Public Hearing Open: 7:56 p.m. Public Hearing Closed: 7:56 p.m. Councilor Marsh suggested clarifying the wording for rental property fees under Business License Fees. Other changes included updating the return check fee for Court from $25 to the City standard of $35, and show fees that applied citywide in one area in the document. For Building Permit Reinstatement fees, if the sum of the original permit subject to reinstatement was less than $50, the reinstatement fee was equal to half the original value, for consistency she proposed changing it to less than $100. Parks and Recreation Superintendent Rachel Dials confirmed there was not a fee at the Daniel Meyer Pool for multiple children same family. Ashland City Council Meeting May 19, 2015 Page 3 of 8 Councilor Marsh/Lemhouse m/s to approve Resolution 2015-15 with a change to the Business License language regarding rental properties, an increase in the return check fee for Court from $25 to $35, and a change on page 17 regarding the building reinstatement fee to clarify that the fee was one half of the original fee up to $100. DISCUSSION Councilor Seffinger/Lemhouse m/s to amend the motion to reduce swimming fees for families that have more than one child to $2 for the remaining children. DISCUSSION: City Attorney Dave Lohman noted Council had the authority to make the fee change but the Parks Commission had originally recommended the amount. Councilor Seffinger explained she had a concern for the safety of children and it was important they learned to swim for safety reasons and the fee punished lower income individuals who could not afford the full amount. Ms. Dials clarified the Parks and Recreation Department had a scholarship program for anyone with a 25% to 75% discount on any program fee and sold punch cards to families at a discounted rate. Councilor Lemhouse commented the amendment supported the Council goal to encourage families to live in Ashland. Councilor Morris would not support the amendment. This was a decision for the Parks Commission, it was their budget, and they set the fees. Councilor Voisin, Rosenthal, and Marsh agreed with Councilor Morris. Roll Call Vote: Councilor Lemhouse and Seffinger, YES; Councilor Marsh, Rosenthal, Voisin, and Morris, NO. Motion failed 4-2. Roll Call Vote on Main Motion: Councilor Lemhouse, Seffinger, Marsh, Rosenthal, Voisin, and Morris, YES. Motion passed. UNFINISHED BUSINESS 1. Approval of cooperative improvement agreement with ODOT concerning Siskiyou Welcome Center and Rest Area Assistant City Attorney Doug McGeary explained Travel Oregon anticipated visitor numbers that would result in staffing the Welcome Center eight hours a day from May through September, and 40 hours a week October through April. Oregon Department of Transportation (ODOT) would complete the water and sewer extension within two years. ODOT was unwilling to reopen the land use decision by Jackson County to request an eight- foot fence instead of the six-foot fence already approved. ODOT did agree to modify and add fencing to improve security, and bolster the gates. They would install a water system capable of servicing fire sprinklers and a hydrant subject to City approval. Adding a metal roof would require reopening the land use decision. The original roof along with the fire sprinkler system would provide adequate fire protection. ODOT would also comply with the City's water curtailment ordinance. Frank Reading, Southwest Oregon Regional Manager for ODOT explained what went into site selection and how it met the Federal Highway Administrations spacing requirements for rest areas. ODOT Area Manager Art Anderson added ODOT would comply with any water curtailment plan the City indicated was necessary. They would install an interior fire suppression system and worked with Public Works Director Mike Faught to ensure there was enough capacity for the system. ODOT would install an 8-inch line versus a 2.5-inch line to the facility and have a trunkline so part of the water went to the rest area facilities and the rest would feed the fire suppression system. The roof of both structures would be made of a composite of fire resistant materials. The intent was keeping the Cascadian style lodge look approved by Jackson County. In addition to the fire hydrant and the 22,000-gallon water storage tanks, and use of fire resistant building materials the facility design was Firewise. ODOT Construction Project Manager Tim Fletcher addressed the gate and fencing at the site. He clarified the reason for not installing an eight-foot fence was that ODOT had already installed some of the fencing and Jackson County had approved the 6-foot fence requirement. Going back to Jackson County to change the fence height would result in a lengthy process that would further delay the project. There was no assurance Jackson County would approve the height change either. Mr. McGeary further clarified changing the fence height would entail another land use hearing and the appeals process. ODOT was providing two fences where there was one prior, and a locked, barbed wire gate. Mr. Anderson noted the request to add barbed wire to the six-foot fence. Ashland City Council Meeting May 19, 2015 Page 4 of 8 Adding a strand of barbed wire to the fence would not make a difference for people trying to get in or out of the facility grounds. It was costly and could require installing new fencing. ODOT had agreed to security cameras, ensuring space for the Oregon State Patrol, and staffing as safety measures. Construction for the Welcome Center and Rest Area would happen concurrently under one construction project. The work would follow the site civil construction project. Once the project started, ODOT would complete it within four years. The timeline included potential unforeseen circumstances. Jeff Hampton, vice president of operations for Travel Oregon explained Travel Oregon used three basic models to staff welcome centers. Direct staffing consisted of employees of Travel Oregon or the Oregon Tourism Commission. Travel Oregon did not screen volunteers or staff at state welcome centers with the exception of the welcome center at Portland International Airport. Temporary staff came from a temporary employment agency that conducted their own employee screening. Volunteers came from the local community. Each Welcome Center had one or a combination of the three employee types. Travel Oregon employees would not staff the proposed Siskiyou Welcome Center. Instead, they would hire temporary staff as well as volunteers. Travel Oregon staff would train the temporary and volunteer employees. Standard hours of operation were 9:00 a.m. to 5:00 p.m. as a minimum with the opportunity to expand the hours based on travel demands. October through April it would no longer function as the Welcome Center but as the location of the Ashland Chamber of Commerce Visitors and Convention Bureau who would staff the facility. It was the intent and expectation of Travel Oregon to be open during that time at least 40 hours a week. In the event Travel Oregon did not have a local entity to staff during these months, they would staff it themselves though a temporary staffing agency. Huelz Gutcheon/2253 Highway 99/Thought the roof of the Welcome Center and Rest Area should be all solar panels. ODOT knew nothing about solar and needed help and time to figure it out. He wanted Council to delay the agreement until ODOT brought back definitive zero net energy plans. President Obama wanted all federal agencies using zero net energy by 2020. He suggested the facility have a couple Tesla electric car fast chargers as well. Stephen Stolzer/1120 Oak Knoll Drive/Spoke on the request for 8-foot fencing. He did not want the people who would use the Welcome Center and Rest Area at night coming over the fence into their homes. He was 78 years old and could climb over a 6-foot fence. That ODOT did not want to go back to Jackson County to get approval on air 8-foot fence was their problem, They should have done that originally. Barbed wire would probably work. He thought they needed to make it more stringent to protect the neighbors. People would gather there at night to transact illicit business and he wanted them confined to the Rest Area. There were only two state police officers patrolling the interstate from Ashland to Grants Pass. He urged Council to hold the line on the fencing. Alex Sol/761 Salishan Court/Expressed frustration and thought the conditions would have guarantees to protect the neighbors surrounding the Welcome Center. It was insulting to him that the ODOT representatives showed what he described as a sense of entitlement and used the request for barbed wire as an example. He stated his daughter was 16 and questioned not having background checks on the employees and related it to the possibility of drug dealers and pedophiles working at the Welcome Center. There were many reasons for the facility and none had to do with the driver coming down the pass with a desperate need to use the restroom. The entire community was in jeopardy for this one man driving down the highway needing to use the urinal. He hoped Council took into consideration above the money interest that there were real people involved with real life implications. Councilor m/s Marsh/Rosenthal to approve and authorize the City Administrator's signature of a Cooperative Improvement Agreement to Provide Water and Sewer Services to the Siskiyou Welcome Center and Rest Area. DISCUSSION: Councilor Marsh explained rest stops played a fundamental, sometimes life saving role for people who were traveling. The addition of the Welcome Center would offer even more services. They could not always predict the hours the Welcome Center would be open, but every day it was benefited the tourist economy. Many travelers made reservations over their cell phones but there were Ashland City Council Meeting May 19, 2015 Page 5 of 8 some that wanted to talk to someone. Regarding crime, there was no evidence statewide that indicated rest areas were centers for crime. The amount of water used by the facility was negligible on the overall city water system. She supported the Welcome Center and Rest Area. Councilor Rosenthal was convinced this was the best possible agreement the City could achieve with ODOT. If Council voted against the motion, the Welcome Center would most likely not happen. ODOT would still build the rest area and the state would not have an obligation to follow through on any of the stipulations the Council tried to negotiate. The City would have a "black eye" in the neighborhood of Rogue Valley communities. He served on the Metropolitan Planning Organization (MPO) and explained Ashland would lose credibility as a partner in tourism advocacy in the Rogue Valley if the Welcome Center did not go forward. The community would also alienate the funders of important local transportation projects in what was a highly competitive arena for state and federal finding. Ashland would be safer if the Welcome Center was a component of the project. This was about water and sewer. Councilor Lemhouse was consistent in not supporting the project and did not believe it was in the spirit of partnership. If it were, Travel Oregon would be doing something different than using the standard formula used for every location. He would rather have drivers stop in Ashland and have the Welcome Center off Exit 14. An eight-foot fence would make a difference and keep people out of the field that provided an access to neighbors' backyards. Some of the security measures were not valid at stopping everything but Council needed to be sensitive to the security perception of the neighbors in the area. Council's job was protecting the city and increasing livability and part of that was being safe and secure in your own home. Much had changed since 1997. To continue to say the Welcome Center was needed and ignore the changes in society and technology seemed to lack awareness. He thought the intention was move forward with the plan no matter what. It told him that government was not as responsive as it should be to the changing times and citizens needs. He strongly disagreed with the project. Councilor Seffinger would have supported the project if it included the barbed wire and the security checks. There were benefits to rest areas but she did not feel the community's needs were met regarding the project. For that reason, she could not morally support the motion. Councilor Morris noted this was a state project on county land with federal money and Ashland water. He thought Travel Oregon and ODOT had done their best to accommodate the City's requests. He acknowledged the perceived fears that a rest area brought but was not sure they were real or an issue. He agreed with Councilor Rosenthal that if Council said no to the water and sewer ODOT would build a rest area anyway and the City would not have any input. He would support the motion. Councilor Voisin thought welcome centers and rest areas were necessary but disagreed with the close proximity to town. A convenience for travelers did not trump the safety concerns of a neighborhood and town. ODOT had not heard citizen or Council concerns. She represented the citizens of Ashland, not ODOT or the federal government. She would not support the agreement. Mayor Stromberg thought the argument as to whether rest areas and welcome centers were good ideas was not relevant to the decision. He was concerned in providing the best possible security for the people in the area. A rest area with a welcome center was more likely safer in terms of the neighborhood than a rest stop by itself. He would vote in favor of the welcome center to ensure more security for the people living in the surrounding neighborhood. If Council voted against the motion, he did not think the community would be safer with just a rest stop. Roll Call Vote: Councilor Marsh, Morris, and Rosenthal, YES; Councilor Voisin, Lemhouse, and Seffinger, NO. Mayor Stromberg broke the tie with a YES vote. Motion passed 4-3. ORDINANCES. RESOLUTIONS AND CONTRACTS 1. Approval of a resolution titled, "A resolution adding a surcharge to water meters for the purpose of generating and dedicating general fund resources for additional work in the forest interface as part of the Ashland Forest Resiliency Program" Mayor Stromberg noted the title of the resolution had changed to, "A resolution adding a surcharge to water meters for the purpose of generating and dedicating general fund resources for additional work as part of Ashland City Council Meeting May 19, 2015 Page 6 of 8 the Ashland Forest Resiliency Program," removing, "...in the forest interface..." Administrative Services Director Lee Tuneberg explained the surcharge would generate approximately $175,000 a year towards Ashland Forest Resiliency (AFR) projects out and come out of the General Fund. He provided three options. Option 1 would include all water and irrigation meters and the rate would be $1.27 per equivalent unit per month. Option 2 excluded municipal meters at $1.31 per unit per month. Option 3 would charge 3/4-inch and 1-inch meters the same at $1.39 per unit per month. The current utility billing systems could handle each option at no additional programming or staffing costs. Councilor Seffi nger/Lem house m/s to approve Resolution 42015-14 with Option 3. DISCUSSION: Councilor Seffinger thought it was a fair way of getting all citizens onboard with the AFR project. It was a vital project for all citizens to protect the city and forest health. Councilor Lemhouse added Option 3 made more sense, charging more for 1-inch meters would become onerous. Everyone depended on water and should do his or her part to fund a project that benefited all. It was also transparent. Councilor Voisin thought the surcharge was unfair. Rates should pay for infrastructure and the operational costs of the infrastructure for water. Adding a surcharge was an unbearable burden for those living below the poverty line or on a fixed income. This was a regressive tax. She suggested capping property tax at 8.92 cents per $ 1,000.00 instead. This progressive tax would apply to the wealthier people that had the most to lose. They should pay more since they had the valuable homes. They could also deduct the increase from their income tax. She would not support the motion. Councilor Seffinger had concerns using property tax. She thought property tax should be reserved for the potential costs of the Public Employee Retirement System (PERS) and rising costs of medical for the City. The health of the forest and forest fire prevention was a concern of all citizens. There were programs to benefit low- incorne individuals. Mayor Stromberg did not agree that using property tax was progressive and the meter charge regressive. Property tax increases affected people on fixed incomes. City Administrator Dave Kanner clarified Southern Oregon University (SOU) and publicly owned property or property owned and operated by a non-profit did not pay property taxes. Councilor Voisin further clarified people working at SOU or non-profits paid their own property tax. Property tax was a progressive tax because of the income tax deduction. Councilor Marsh explained no one liked raising fees. This was a critical project and the utility fee had three qualities that were essential in a new fee. One, the fee was transparent, two, there was a nexus between the source and the use, and third, the funds were dedicated. Councilor Lemhouse raised a point of order regarding property taxes when this was a deliberation on the utility rate surcharge. Mayor Stromberg agreed with the point of order. Roll Call Vote: Councilor Seffinger, Rosenthal, Morris, Marsh, and Lemhouse, YES; Councilor Voisin, NO. Motion passed 5-1. NEW AND MISCELLANEOUS BUSINESS 1. Letter to US Forest Service regarding Mt. Ashland Association summer activities Mayor Stromberg explained the City received a letter from Donna Mickley at the U.S. Forest Service regarding a hearing deadline of May 29, 2015 to comment on Mt. Ashland Associations (MAA) proposed summer activities. Council addressed the letter and suggested prohibiting smoking instead of limiting smoking to the parking lot. Councilor Voisin expressed concern on the lack of public comment. The activities would occur during an unprecedented drought. She preferred drafting another letter. Councilor Lemhouse/Marsh m/s to forward to the US Forest Service the proposed letter the Mayor presented with the corrections Council suggested. DISCUSSION: Councilor Lemhouse noted concern regarding the expansion often did not extend to MAA. People wanted MAA to have a better economic plan with year round activities and this was a responsible response to that request. Supporting MAA's economic development benefited Ashland. Councilor Marsh thought the amendment to prohibit smoking could have a counter effect and push people off paved areas creating a more dangerous situation than allocating a smoking Ashland City Council Meeting May 19, 2015 Page 7 of 8 area. Councilor Seffinger noted the term smoking did not specify marijuana and preferred prohibiting smoking of any substances. Councilor Morris clarified it was federal land so smoking marijuana was already prohibited. He supported the letter as drafted. Councilor Voisin explained she did not want to curtail human involvement in the forest area. The headwaters of the watershed were at stake. This would be the second worst drought year on record. It was the City's responsibility to protect the headwaters and not MAA's economic development. She preferred waiting until drought conditions changed before supporting summer activities. Mayor Stromberg further explained MAA was dealing with significant financial issues due to the weather and were trying to reinvent the business. If MAA failed, the U.S. Forest Service could find a new entity to take over the special use permit and the City could not withhold approval of that change. Councilor Rosenthal/Lemhouse to amend the signature line to include Mayor Stromberg on behalf of and list each Councilor supporting the letter. Roll Call Vote: Councilor Morris, Lemhouse, Seffinger, Rosenthal, and Marsh, YES; Councilor Voisin, NO. Motion passed 5-1. Roll Call Vote on main motion as amended: Councilor Lemhouse, Rosenthal, Seffinger, Morris, and Marsh, YES; Councilor Voisin, NO. Motion passed 5-1. 2 7th quarterly financial report of the biennium Councilor Lemhouse/Marsh m/s to accept the seventh quarter financial report biennium (BN) 2013-2015. Voice Vote: all AYES. Motion passed. ORDINANCES, RESOLUTIONS AND CONTRACTS-continued 1. First reading by title only of an ordinance titled, "An ordinance amending Chapter 11.29 to authorize City Council to establish presumptive parking violation fines by resolution" City Attorney Dave Lohman explained current practice added a $25 penalty if an individual received a fourth parking violation. At five, the penalty was $50 and not enforced for further violations. The ordinance stated the fifth violation and any following received a $50 penalty. He proposed Council retain the ordinance and have the City start imposing the current provision. Councilor Lemhouse/Seffinger m/s to approve the first reading by title only of an ordinance titled, "An Ordinance Amending Chapter 11.28 to Authorize City Council to Establish Presumptive Parking Violation Fines by Resolution," and move to second reading. DISCUSSION: Councilor Voisin wanted to know who was receiving the multiple violations. Mr. Lohman responded there was not enough information that determined whether the individual was a city or business employee. Councilor Marsh thought it was premature to start enforcing standards Council had not discussed. Mr. Lohman clarified voting yes on the motion would continue the current ordinance provision that required the $50 fine for each violation after the fourth. Council could strike "...for each parking violation they receive in that year," in Section 11.28.110(A)(2). Councilor Lemhouse raised a point of clarification and asked whether Council could speak with the Judge between first and second reading. City Administrator Dave Kanner explained the Judge's schedule precluded her from meeting with the Council until August 17, 2015. Councilor Marsh/Seffinger m/s to amend the motion to eliminate the words "...for each parking violation they receive in that year," from paragraph two, Section 11.28.110(A)(2) and from the table under Additional Penalty. DISCUSSION: Councilor Marsh did not think it was appropriate to enforce a standard not previously enforced when Council would review the parking fine structure in the future. Councilor Seffinger was comfortable with the change. Councilor Lemhouse leaned towards voting against the amendment. Waiting to hear from the Judge in August burdened the City and it was appropriate to move forward. Roll Call Vote: Councilor Rosenthal, Seffinger, and Marsh, YES; Councilor Morris, Lemhouse, and Voisin, NO. Mayor Stromberg broke the tie with a NO vote. Motion failed 4-3. Ashland City Council Meeting May 19, 2015 Page 8 of 8 Roll Call Vote on the main motion: Councilor Morris, Seffinger, Lemhouse, and Voisin, YES; Councilor Rosenthal and Marsh, NO. Motion passed 4-2. 2. First reading by title only of an ordinance titled, "An ordinance amending Chapter 2.10.040 to revise standards for a quorum and for number of votes needed for official action at meetings of advisory commissions and boards" City Attorney Dave Lohman explained at the last meeting Council majority agreed to count only the currently serving Council approved appointees for a quorum and have at least three voting in favor of any motion in order for it to pass. Councilor Rosenthal requested that Council not make a motion. The proposal was an over-reaction to a symptom and would not remedy the root cause. The problem involved a recent difficulty in filling commission vacancies, specifically the Public Arts Commission and the Tree Commission. He was not convinced there was a crisis that warranted changing the code. The better situation would be an analysis on why there were issues with membership and recruitment and review the recruiting process. Councilor Lemhouse suggested tabling the issue indefinitely, form a subcommittee with the mayor, two councilors, and staff, analyze reasons why it was difficult to fill vacancies on commissions and bring a plan to Council at a future meeting. Councilor Lemhouse/Voisin m/s to postpone this item indefinitely and appoint a Council subcommittee to examine the commission vacancy issue. DISCUSSION: Councilor Lemhouse would be open to adjusting quorum after looking into recruitment and retention. Councilor Voisin did not think lack of quorum was a large issue at this point. Councilor Seffinger added commissions made many important recommendations to Council and having a full commission make those recommendations was important. Roll Call Vote: Councilor Lemhouse, Voisin, Morris, Marsh, Seffinger, and Rosenthal, YES. Motion passed. OTHER BUSINESS FROM COUNCIL MEMBERS/REPORTS FROM COUNCIL LIAISONS Councilor Voisin announced Historic Preservation events that would occur May 17 through May 23. Mayor Stromberg and Mr. Kanner noted May 20, 2015 was the dedication of Ashland Creek Park. Councilor Lemhouse announced at the May 15, 2015 Public Arts Commission meeting in addition to the utility box art forwarded to Council for approval, the Commission took initial designs for the gateway art project in front of Fire Station 1. He encouraged citizens to look at the items suggested. A review panel would make a selection and the Public Arts Commission would make a recommendation to Council. ADJOURNMENT OF BUSINESS MEETING Meeting was adjourned at 10:29 p.m. Barbara Christensen, City Recorder John Stromberg, Mayor CITY OF ASHLAND Council Communication June 2, 2015, Business Meeting Update on 2015 Drought Plan FROM: Michael R. Faught, Public Works Director, Public Works Department, faughtm@ashland.or.us SUMMARY This is an informational communication updating the Council on a plan for a drought summer. While the current snow pack is zero, Ashland Creek flows are running 3.5 to 4 million gallons per day (mgd) higher than last year at the same time. That being said, staff continues to prepare for the 2015 drought. Staff will maintain a full reservoir for as long as possible by adding Talent Irrigation District (TID) and Talent, Ashland and Phoenix (TAP) water as needed. The community will be asked to reduce its water use to 4.5 mgd. The Water Conservation division will assist customers with ways to reduce water use, and as a last resort, the City will implement the water waste and curtailment steps as outlined in the Municipal Code. BACKGROUND AND POLICY IMPLICATIONS: Ashland must prepare for a second consecutive drought summer. The current snow pack levels are at zero; however, with the recent rains, Ashland Creek flows are running 3.5 to 4 mgd higher than last year at the same time. In addition, both lakes that supply water to TID are less than half full: Howard Prairie is 41% full and Hyatt Lake is 37% full (see attached, `US Bureau of Reclamation, Pacific Northwest Region Bear Creek and Little Butte Creek Basins'). Staff is preparing for a drought given that the current snow pack may not be sufficient to meet Ashland's summer water supply needs. The plan of action is as follows: 1. Ashland residents to voluntarily reduce water usage to 4.5 mgd; 2. Keep Reeder Reservoir full (see `2015 Drawdown Curve' graph) for as long as possible; 3. Add TID (up to 2 mgd) when Ashland Creek flows no longer keep Reeder Reservoir full, 4. Add TAP when both Ashland Creek flow and TID water are not sufficient enough to keep Reeder Reservoir full (staff will be prepared to start using TAP water by August 15"') If there is a need to use 2 mgd of TID water, no TID water will be sent past the pump station at Park Estates, and downstream TID customers will not receive TID water. If additional TID water is needed, the remaining sections of the TID water canal (between Walker and Park Estates) will also be diverted to the plant. If this occurs, then those TID irrigation customers will not be allowed to use TID water for irrigation purposes. The reservoir graphs (below) provide a daily look at Ashland's water supply over last year and 2015 year-to-date. The red line represents the theoretical reservoir use rate necessary to adequately meet Ashland's water supply needs. The blue line represents the current reservoir level. If at any point the Page 1 of 4 VErN CITY OF -ASHLAND demand on Reeder Reservoir drops below the theoretical drawdown curve as shown in the chart below, staff is prepared to implement the water curtailment strategies. 2014 drawdown curve 100 60 40 20 CID @@ 1 2015 drawdown curve 100 80 60 40 20 Page 2 of 4 CITY OF -AS H LA N D The water waste and curtailment steps, as outlined in the Municipal Code, will be implemented if voluntary water usage reductions, TID, and TAP all fail to keep the reservoir full. The following chart provides a summary of allocations at each stage of curtailment. 1 3,600 26,928 20% 2 2,504 18,700 30% 3 1,800 13,464 40% 4 900 6,732 550% Additional Drought 2015 Actions • Update the 2015 Drought section of the City's website; • Purchase 2015 blue lawn signs that say "Use water wisely" to be placed in the public right- of-way throughout town; • Scheduling public presentations on what the community can do to conserve at local civic clubs, the Mayor's Town Hall show (July 29th), and interviews with the local media; • Participated in a regional drought summit, • The first multi-departmental water curtailment committee meeting is scheduled for June 2nd Conservation As our customers become aware of the severity of the 2015 drought, the most common question is usually "what can I do to reduce my water use?" Fortunately, the city has a robust water conservation program, so when asked this question, staff will direct them to our water conservation specialist for specific short and long term water conservation recommendations. The water conservation team offers our water customers a free irrigation system and indoor water use evaluation. In most cases, this detailed evaluation of individual systems will uncover ongoing water waste (bad sprinkler heads, leaking faucets or toilets, etc). In addition, the city provides free water efficient shower heads, faucet aerators, and soil moisture meters that can help our customer reduce water consumption. Page 3 of 4 pla CITY OF ASHLAND STAFF RECOMMENDATION AND REQUESTED ACTION: N/A SUGGESTED MOTION: N/A ATTACHMENTS: US Bureau of Reclamation, Pacific Northwest Region Bear Creek and Little Butte Creek Basin Level Pap 4 of 4 11FAW&A US Bureau of Reclamation, Pacific Northwest Region Bear Creek and Little Butte Creek Basins 05 25;2015 4 Qk Eagle rl f /e 4 li~ I , " _ f! F jut t, 1. E lltitt Is C CO 54 f! F Icitle EL EIC= 3 S:F= t~ Hi 190s t eta, F.tl1 : i:+ a tv h~ ! 11rDO 45 0: Medford F1I ABC Phoeni~_ Tale _sf s E-S() 25cf Hvn rtlP Fu44 4 4IctRtl Hit f 5 c t t 1 r K~ E _4~ f "FO r5c. s 411f, RM F'w n, T, rns C~ l' PROCLAMATION ~ y By act of Congress of the United States dated June 14, 1777, the first official flag of the United States was adopted. a IL i3_ • By act of Congress dated August 3, 1949, "National Flag Day" was designated each year as June 14.E oJ~ • The Congress has requested the President to issue annually a y proclamation designating the week in which June 14 occurs as National Flag Week. , • Flag Day celebrates our nation's symbol of unity, a democracy in a t, r republic, and stands for our country's devotion to freedom, to the rule of all, and to equal rights for all. G • We pay our respect to all of the many veterans who have served the armed forces of their country, ~~fTir a : 411 NOW, THEREFORE, 1, John Stromberg, Mayor of Ashland, do hereby ~r proclaim June 14, 2015, as r r FLAG DAY in the City of Ashland. and urge all citizens of Ashland to join in with the Ashland Elks Lodge #944 to Pledge of Allegiance to our Flag and Nation, at noon on Sunday, June 14, at the Ashland downtown Plaza. Dated this 2°a day of June, 2015. 9 ~ s t John Stromberg, Mayor Barbara Christensen, City Recorders , Z ed~ 16! non 1'\~ an CITY OF ASHLAND Council Communication June 2, 2015, Business Meeting Liquor License Application for Duke Tuffy dba Southern Oregon Growlers, LLC FROM: Barbara Christensen, City Recorder, christeb@ashland.or.us SUMMARY Approval of a Liquor License Application from Duke Tuffy dba Southern Oregon Growlers, LLC at 345 Lithia Way. BACKGROUND AND POLICY IMPLICATIONS: Application is for a "new license." The City has determined that the license application review by the City is set forth in AMC Chapter 6.32 which requires that a determination be made to determine if the applicant complies with the City's land use, business license and restaurant registration requirements (AMC Chapter 6.32) and has been reviewed by the Police Department. In May 1999, the Council decided it would make the above recommendations on all liquor license applications. FISCAL IMPLICATIONS: N/A STAFF RECOMMENDATION AND REQUESTED ACTION: Endorse the application with the following: The City has determined that the location of this business complies with the city's land use requirements and that the applicant has a business license and has registered as a restaurant, if applicable and has been reviewed by the Police Department. The City Council recommends that the OLCC proceed with the processing of this application. SUGGESTED MOTION: Under Consent agenda item, a motion to approve liquor license for Duke Tuffy dba Southern Oregon Growlers, LLC. ATTACHMENTS: Liquor License Application Page 1 of l Iai, OREGON LIQUORONTROL COMMISSION LIQUOR LICENSE APPLICATION Application Is being made for. CITY AND COUNTY USE ONLY LICENSE TYPES ACTIONS Date application received: ❑ Full On-Premises Sales ($402.60/yr) ❑ Change Ownership ❑ Commercial Establishment © New Outlet The City Council or County Commission: ❑ Caterer Greater Privilege ❑ Passenger Carrier ❑ Additional Privilege (name of city or county) ❑ Other Public Location ❑ Other recommends that this license be: ❑ Private Club ® Limited On-Premises Sales ($202.60/yr) O Granted 13 Denied ©Off-Premises Sales ($100/yr) By: with Fuel Pumps (signature) (date) H Brewery Public House ($252.60) Name: Winery ($250/yr) ❑ Other: Title: 90-DAY AUTHORITY OLCC USE ONLY ❑ Check here if you are applying for a change of ownership at a business that has a current liquor license, or if you are applying for an Off-Premises Application Recd by: Sales license and are requesting a 90-Day Temporary Authority / Dater APPLYING AS: ❑Limited ❑Corporation OUmited Liability ❑Individuals Partnership Company g0-day authority: t] Yes • No 1. Entity or Individuals applying for the license: [See SECTION 1 of the Guide] ,D Southern Oregon Growlers, LLC 2. Trade Name Met): Southern Oregon Growlers 3. Business Location: 345 Lithia Way Ashland Jackson OR 97520 p (number, street, rural route) (city) (county) (state) (ZIP code) 4. Business Mailing Address: 901 NW E Street Grants Pass OR 97526 (PO box, number, street, rural route) (city) (state) (ZIP code) 5. Business Numbers: TBD (plane) (fax) 6. Is the business at this location currently licensed by OLCC? (]Yes XINo 7. If yes. to whom: Type of License: 8. Former Business Name: 9. Will you have a manager? MYes []No Name: TBD (manager must fill out an Individual History form) 10. What is the local governing body where your business is located? Ashland (name of city or county) 11. Contact person for this application: Duke Tufty 503-517-8137 (name) (phone number(s)) 621 SW Morrison St., Ste. 1300, Portland, OR 97205 503-273-9135 dt@wysekadish.com (address) (fax number) (e-mall address) I unders d t If y answers are not true and complete, the OLCC may deny my license application. Appi can gn s) an at Dat~,S_ ® Date ® Date O Date 1-800452-OLCC (6522) • www.oregon.gov/oloc t(OV0&2011) CITY OF ASHLAND Council Communication June 2, 2015, Business Meeting Appointment to Planning Commission FROM: Barbara Christensen, City Recorder, christeb(aashland.or.us SUMMARY Confirm Mayor's appointment of Roger Pearce to the Planning Commission with a term to expire April 30, 2017. BACKGROUND AND POLICY IMPLICATIONS: This is confirmation by the City Council on the Mayor's appointment to the Planning Commission. Ashland Municipal Code (AMC) Chapter 2.17.020 STAFF RECOMMENDATION AND REQUESTED ACTION: Motion to approve appointment of Roger Pearce to the Planning Commission with a term to expire April 30, 2017. SUGGESTED MOTION: Motion to approve Roger Pearce to the Planning Commission with a term to expire April 30, 2017. ATTACHMENTS: Application Page I of I CITY OF -ASHLAND APPLICATION FOR APPOINTMENTTO CITE' C:OMMISSIO\1CONIMITTEE Please type or print answers to the folloyv in- questions and submit to the Cite Recorder at Cite hall. 2t1 E Main Street. or email t :s. If you have any questions, please feel free to contact the City Recorder at 488-5307. Attach additional sheets if necessary. Name V- 066- C Reques11111" to serve oil V1 I 'V\ t~ {CommissionlGopwi4gee3 Address^___k0ld fMe2V-~Chn ..S ~ Veti 1x-3141ot,jL Occupation Phone: Home 'S(,L) ~ f)Z- 46-41 Fork ?.t7(o 22.40 • 11x13 Email? 'i y^c a r 2.2 wt A t i . C.0" 1. Education Background What schools have ~-ou attended'.) ca kitt c2 _ "Lq(VGsi d f Uv-, r What de(rees do tiou hold? What additional training or education have you had that would apply to this position?''• G4, 4h Avg %1 e t k Unw► 14 _t3%,.- L4W 0~ 7Z ~",gVI V3 1 f 2. Related Experience What prior work experience have you had that would help you if you were appointed to this position'? ti~Z► S ~ ca m- 04 -.aAaq,. ?2 l►T LL C. w., T Y"~L SAM t rlt+\Y'e.e%,,C'-+ c.,G V*1 t1r-~~ . 7 LtAoijt laM~4a► 1. P I#AL/H litr+~ QeV]~` ~d+1Y t d s.tSe P l *a~ k c~ i P% can t'~ VP r1 , fro you feel it vkould be advantage( is for you to ye further training in this field, such as attending conferences or seminars') "'lly'? I lamd ,\r vV11 A Yt - t1 y' P.! sOS. ~ _ c.1 WA%Af Yf~° _~'Y+ 3. Interests Why are you applying for this position`? ivux -p- 0,L A V% 4-AA i VO K .[,1 l OV% Ch 1 i y1 S I VN 9'a %A y 1 42 ln 1 1 1 an L11 VV 4. Availability ~tlwvtw~U I Are r ou available to attend special meetings- in addition to the retulark, scheduled meetings'? Do you prefer day or evening meetings" as , ~ & 4+-R.,9 ~ cw 1=-4%4 I i~-j 5. Additional Information HOB'. long have %'ou lived in this community? 'rat It7+;~ri 2 41 Please use the space, below to summarize anv additional qualifications you have for this position . Se e a f- 9- Q e-4 QV It, f 1-kA -ai4 rev, i Imo? Q I S cM1ME=W*' 4 1 t t Vz, 1 \jAe -6 se..r °c Date s i a d ure ATTACHMENT TO APPLICATION FOR APPOINTMENT TO PLANNING COMMISSION Additional qualifications for appointment to Planning Commission: My spouse and I have known Ashland for many years. Like many others, we were first introduced to the community by coming to the Oregon Shakespeare Festival, but soon grew to love the progressive and liberal spirit of the City of Ashland. Almost ten years ago, we decided to move here for retirement (which is turning out to be decidely semi-retirement) and purchased our residence at 1010 Morton Street. We were finally able to slow down our Seattle work life and move here full-time in April 2013. In Seattle, I worked an attorney and partner in the Foster Pepper PLLC law firm, which is a large firm with a very diverse practice - including the broadest and deepest land use practice in Washington. For years, we had a Portland office, and I worked with those attorneys on a number of projects in Oregon. At Foster Pepper, I had the opportunity to work for both municipal clients and for private clients in land use matters. There is no part of the land use process in which I have not been involved over the part 25 years - working on legislative projects; working on and advising public and private clients on environmental review; appearing before boards and commissions; advising cities and private clients; and representing cities, other municipal entities, and private interests in land use matters in district and appellate courts. Since moving to Ashland, I have continued to work for several private clients in the Seattle area, but I have deliberately tried to phase that work out so that I can be fully involved in the Ashland and Rogue Valley community. In Ashland, I have worked with the Ashland New Plays Festival and with Southern Oregon Climate Action Now. And I would very much like to get more involved with the planning and land use process in my new home. I consider myself politically progressive and liberal, but I don't have an ideological ax to grind in the land use planning area. I believe that elected officials -the Mayor and Councilmembers - should set the policy direction. The Planning Commission can be a valuable research and recommendation tool for those elected officials. The City of Ashland seems to have done a pretty good job to date, and the town works well as far as I can tell. But there are always big planning challenges in accommodating smart growth in the community, providing opportunities for a range of housing options, providing opportunities for living-wage jobs, but at the same time keeping our city livable, welcoming, and pedestrian friendly. Thank you for considering my application. I think I could be of service to the city as a planning commissioner. Roger Pearce 1010 Morton Street Ashland OR 97520 Cell: 206 226-1623 Email: pearcer22@gmail.com CITY OF ASHLAND Council Communication June 2, 2015, Business Meeting Jackson County Supervising Physician Support Agreement FROM: John Karns, Fire Chief, Ashland Fire & Rescue, karnsj@ashland.or.us SUMMARY This is an agreement between Jackson County Health and Human Services and the City of Ashland for support of the supervising physician program. This agreement helps fund a 0.25 FTE office assistant for the supervising physician program. BACKGROUND AND POLICY IMPLICATIONS: As an EMS provider in Jackson County, Ashland Fire & Rescue is required to work under direction of a designated supervising physician. This agreement helps fund a 0.25 FTE office assistant who will support the supervising physician program. Among the duties of this office assistant are maintaining phone access, maintain and update the EMS standing orders, maintain web page, maintain EMT and first responder training records, attend meetings, take and transcribe minutes, maintain records of correspondence of the supervising physician, and other duties. COUNCIL GOALS SUPPORTED: N/A FISCAL IMPLICATIONS: City of Ashland will pay Jackson County $2,136.26. This is budgeted in Ashland Fire & Rescue's EMS Division budget 110.07.13.00.604150, Physician/Health. STAFF RECOMMENDATION AND REQUESTED ACTION: Staff recommends that Council approve the agreement with Jackson County for supervising physician support. SUGGESTED MOTION: I move to approve the interagency agreement with Jackson County Health and Human Services for support of the supervising physician program. ATTACHMENTS: Copy of interagency agreement Page 1 of I Interagency Agreement This agreement is between Jackson County acting by and through its' Department of Health and Human Services, hereinafter called "County", and the City of Ashland. In support of the Supervising Physician program both parties agree to the following: 1. Effective Date and Duration. This agreement shall become effective on the date in which the last party has signed the agreement. Unless earlier terminated or extended this agreement shall expire on June 30, 2016. 2. Statement of Work. The statement of work is contained in Exhibit A hereto and by this reference made a part thereof. 3. Consideration. City of Ashland will pay to Jackson County $2,136.26 pursuant to this agreement. This charge is comprised of a run fee of $0.67 per run and weighted fees based on the level of EMT. Emergency Medical Responders are weighted at $1.00, Emergency Medical Technicians are weighted at $1.25, Advanced Emergency Medical Technicians at $1.25, EMT Intermediates at $1.50 and Paramedics at $2.00. In consideration the County shall provide centralized clerical support in the form of a 0.25 F.T.E. Office Assistant IV to the Supervising Physician program in Jackson County and all necessary office supplies to carry out activities as outlined in Exhibit A. County agrees to employ, supervise and provide directions to ensure successful work of this staff person. 4. Access to Records. Duly authorized representatives of City of Ashland shall have access to records concerning this centralized EMS clerical office and staff for this Supervising Physician program. 5. Termination. This contract may be terminated by the mutual consent of the parties, or by either party upon thirty (30) days notice unless a shorter period is agreed to by both parties. Notice of termination shall be accomplished in writing, and delivered by certified mail or in person. 6. Indemnification. To the extent permitted by Article 11, Section 7 and Article 11, Section 10 of the Oregon Constitution and the Oregon Tort Claims Act, each party hereto agrees to indemnify, within the limits of the Oregon Tort Claims act, and save the other harmless from any claim, liability or damage resulting from any error, omission, or act of negligence on the part of the indemnifying party, its officers, employees or agents in the performance (or nonperformance) of its responsibilities under this Agreement, provided the parties will not be required to indemnify the other for any such liability arising out of the wrongful act of the other's officers, employees or agents. 7. HIPAA Compliance. If the work performed under this Interagency Agreement is covered by the Health Insurance Portability and Accountability Act or the federal regulations implementing the Act (collectively referred to as HIPAA), City of Ashland agrees to perform the work in compliance with HIPAA. Without limiting the generality of the foregoing, if the work performed under this Interagency Agreement is covered by HIPAA, City of Ashland shall comply with the following: (i) Privacy and Security of Individually Identifiable Health Information: City of Ashland, its' agents, employees and subcontractors shall protect individually identifiable health information obtained or maintained about participants of City of Ashland programs funded by this agreement from unauthorized use or disclosure, consistent with the requirements of HIPAA. This Interagency Agreement may be amended to include additional terms and conditions related to the privacy and security of individually identifiable health information. 8. Merger Clause. This Interagency Agreement and attached Exhibit constitute the entire agreement between the parties. No waiver, consent, modification or change of terms of this Interagency Agreement shall bind either party unless in writing and signed by both parties. Such waiver, consent, modification or change, if made, shall be effective only in the specific instance and for the specific purpose given. There are no understandings, agreements, or representations, oral or written, not specified herein regarding this contract. City of Ashland, by signature of its authorized representative, hereby acknowledges that he/she has read this Interagency Agreement, understands it, and agrees to be bound by its terms and conditions. Signature Date Danny Jordan Date County Administrator Title I II Exhibit A Jackson County Supervising Physician Clerical Support Jackson County agrees to supervise, provide direction, and ensure successful work for a 0.25 F.T.E. Office Assistant IV. The goal is to provide centralized clerical support for the Supervising Physician program in Jackson County and specific coordinated emergency medical service functions. Specific Activities ♦ To maintain a phone access line and message system. ♦ To maintain and update the Standing Orders for all EMS agencies as requested by the Supervising Physician(s). ♦ To maintain a Web page and Internet e-mail access. ♦ To assure publication and distribution of an EMS newsletter. ♦ To maintain attendance at peer reviews. ♦ To maintain a listing of EMS educational activities. i ♦ To maintain EMT and First Responder training records provided by the County or the Supervising Physician program. ♦ To attend meetings, take and transcribe minutes of EMS/QA and other meetings as assigned. ♦ To provide general clerical support for the Supervising Physician(s). ♦ To assist the Supervising Physician(s) in preparing for Peer Reviews. ♦ To complete special projects as assigned. ♦ To maintain records of correspondence of the Supervising Physician(s). CITY OF SHLAND Council Communication June 2, 2015, Business Meeting Declaration and Authorization to Dispose of Surplus Property in a Sealed Bid Auction FROM: Lee Tuneberg, Finance Director, lee.tuneberg~criashland.or.us SUMMARY City staff intends to facilitate a sealed bid auction in accordance with AMC 2.54 to dispose of City property that has been declared surplus property. BACKGROUND AND POLICY IMPLICATIONS: Near the end of each fiscal year, City staff conducts a sealed bid auction in accordance with AMC 2.54 to dispose of City property that has been declared surplus property. The public sale allows the general public, including local citizens of Ashland, to participate in the sealed bid auction process. Thus far, there has been a great deal of interest, numerous sealed bids received, and a successful turn-out at each of the previous auctions. Therefore, staff recommends that we conduct another sealed bid auction to dispose of the property being declared surplus. Please refer to AMC Chapter 2.54 for more information regarding the disposal of surplus property COUNCIL GOALS SUPPORTED: N/A FISCAL IMPLICATIONS: Disposing of this property will avoid any future storage, handling and labor costs. The City equipment fund (730) and Parks fund (411) will receive the revenue generated by the sealed bid auction under the category of "sale of assets" (480.310). STAFF RECOMMENDATION AND REQUESTED ACTION: Staff recommends that the vehicles and equipment on the attached list, and miscellaneous low dollar items no longer of value to the City and held in storage for the sealed bid auction, be declared surplus property and City staff be given authority to conduct a sealed bid auction in accordance with AMC 2.54. SUGGESTED MOTION: The Council, acting as the Local Contract Review Board, moves to declare the property shown on the list titled, "Sealed Bid Auction - June 2015" surplus, allow City staff to include any additional low dollar items offered up by departments and/or located in storage areas prior to advertising for the sealed bid auction, and gives City staff authority to conduct a sealed bid auction. Pale 1 of 6 CITY OF ASHLAND ATTACHMENTS: The list of vehicles and equipment (major items) intended to be declared as surplus property is as follows: SEALED BID AUCTION - JUNE, 2015 EQUIP DEPT DESCRIPTION QUANTITY /L,OT# 452 AFN 2000 Ford E-350 w/ALTEC A200SV, Vin 1 #1 FTSE34L2YHB 18046, 79,167 Miles 477 Electric 2000 Ford E-350 w/ALTEC A200SV, Vin 1 4IFTSE34LXYHBI 7937,106,880 Miles 624 Police 2009 Police Dodge Charger, Vin 1 42B3KA43VX9H607926, 94,619 Miles 405 Wastewater 2001 Chevrolet Camera Van G30, Vin 1 #1GMG31MY1236157, 89,458 Miles 295 Facilities 1997 GMC Chevrolet Savanna Van, Vin 1 #l GTGG25RXV 1040083, 79,472 Miles 483 Building 2004 Jeep Liberty, Vin 41J4GL48KX4W105077, 75,884 1 Miles 749 Parks 2007 Kromer B-100 Field Striper, 181 Hours 1 675 Parks 2003 Pioneer Brite Striper 1500 Field Striper l 651 Parks 2000 Toro 5500-D Fairway Mower (5) Gang, 5,072 Hours 1 841 AFN 2011 Alton-D12120 Diesel Generator 12 volt, 200 Hours 1 727 Parks Stihl BR-420 Leaf Blower 1 786 Parks Parker Hurricane HC8880K Blower 1 551A Street 2006 Stihl BG-85 Blower 1 780 Parks Toro 21" Walk Behind Lawn Mower (two cycle) 1 1 Parks MTD Chipper/Shredder 3.5hp Briggs and Straton 1 2 Police Trailer Axle w/Wheels, Tires and Springs 35001b 1 2 Fleet Chemsearch Parts Washer 1 580A Street Husk Hotsaw (Parts) 1 286A Water Stihl TS760 AV 1 4 Electric Stihl 021 Chainsaw 1 5 Facilities Storage Bins for Van 1 Lot 6 Facilities 2-drawer black file cabinet (letter size) 1 7 Facilities Computer/printer stand with casters 1 8 Facilities Podium 1 9 Facilities Ricoh printer / copier 1 10 Facilities Wood office chairs with dark green fabric and casters 5 11 Facilities Ricoh printer 1 Page 2 of 6 M CITY OF SHLAND LOT # DEPT DESCRIPTION QUANTITY 12 Facilities 5-drawer light beige lateral filing cabinet 1 13 Facilities Samsung Cash Register Model ER-650 1 14 Facilities Conference table (6 feet long) 1 15 Facilities Coffee table (4 feet long) 1 16 Facilities Swivel desk chairs - light purple with black plastic frames 2 17 Facilities Large swivel office chair - grey fabric with black plastic 1 18 Facilities Desk with return 1 19 Facilities Desks (light color/dark color) 1 20 Facilities Desk (light color/dark color) 1 21 Facilities Fabric/steel frame bench 1 22 Facilities Table with drawer 2.5'x3.5' feet I 23 Facilities Table - 2.5'x3.5' feet 1 24 Facilities Mops 2 25 Facilities Desk lamp 1 26 Facilities Mirror - 40"x20" feet 1 27 Facilities Office chair with blue fabric and black steel frame 1 28 Facilities White board - 6'x4' 1 29 Facilities White board - 61x4' 1 30 Facilities Wood file cabinet with 2 drawers I 31 Facilities Organ 1 32 Facilities Space Heater 1 33 Facilities Space Heater 1 34 Facilities 4-drawer black file cabinets 1 35 Facilities 4-drawer black file cabinets 1 36 Facilities Wood/laminate cabinet 1 37 Facilities Miscellaneous restroom equipment 1 Lot 38 Facilities Gym lockers (I set) 1 39 Facilities Gym lockers (1 set) 1 40 Facilities Gym lockers (1 set) 1 41 Facilities Gym lockers (1 set) 1 42 Facilities Gym lockers (1 set) 1 43 Facilities Gym lockers (1 set) 1 44 IT 17" Monitor, CTL 171 Lx 1 45 IT 17" Monitor, CTL 171 Lx 1 46 IT 17" Monitor, CTL 171 Lx 1 47 IT 17" Monitor, CTL 171 Lx 1 48 IT 17" Monitor, CTL 171 Lx 1 49 IT 17" Monitor, CTL 171 Lx 1 50 IT 17" Monitor, CTL 171 Lx 1 51 IT 17" Monitor, CTL 171 Lx 1 52 IT 17" Monitor, CTL 171 Lx 1 Page 3 ot'6 CITY OF -ASHLAND LOT # DEPT DESCRIPTION QUANTITY 53 IT 17" Monitor, CTL 171 Lx 1 54 IT 17" Monitor, CTL 171 Lx l 55 IT 17" Monitor, CTL 171Lx 1 56 IT 17" Monitor, CTL 171 Lx I 57 IT 17" Monitor, CTL 171Lx 1 58 IT 17" Monitor, CTL 171Lx l 59 IT 17" Monitor, CTL 171Lx 1 60 IT 17" Monitor, CTL 171 Lx 1 61 IT 17" Monitor, CTL 171 Lx 1 62 IT 17" Monitor, CTL 171 Lx l 63 IT 17" Monitor, CTL 171Lx 1 64 IT 17" Monitor, CTL 1711-x 1 65 IT 17" Monitor, CTL 171Lx 1 66 IT 17" Monitor, CTL 171 Lx l 67 IT 17" Monitor, CTL 171Lx 1 68 IT 17" Monitor, CTL 171 Lx l 69 IT 17" Monitor, CTL 171 Lx 1 70 IT 19" Monitor, CTL, 191 Lx 1 71 IT 17" Dell Monitor 1 72 IT 19" Monitor, ACER 1 73 IT 19" Monitor, ACER 1 74 IT 19" Monitor, ACER 1 75 IT 19" Monitor, ACER 1 76 IT 22" Dell Monitor 1 77 IT 22" Dell Monitor 1 78 IT 22" Dell Monitor 1 79 IT 22" Dell Monitor l 80 IT 22" Dell Monitor 1 81 IT 22" Dell Monitor 1 Panasonic Toughbook Laptop, CF30, 2GB RAM, l .66GHz 82 IT Core Duo, 80GB HD I Panasonic Toughbook Laptop, CF30, 2GB RAM, 1.66GHz 83 IT Core Duo, 801313 HD 1 Panasonic Toughbook Laptop, CF30, 2GB RAM, 1.66GHz 84 IT Core Duo, 80GB HD 1 Panasonic Toughbook Laptop, CF30, 2GB RAM, 1.66GHz 85 IT Core Duo, 80GB HD 1 Panasonic Toughbook Laptop, C1730, 2GB RAM, 1.66GHz 86 IT Core Duo, 80GB HD I Panasonic Toughbook Laptop, CF30, 2GB RAM, 1.66GHz 87 IT Core Duo, 80GB HD 1 Panasonic Toughbook Laptop, CF30, 2GB RAM, 1.66GHz 88 IT Core Duo, 80GB HD I Page 4 of 6 ~ll CITY OF -ASHLAND LOT # DEPT DESCRIPTION QUANTITY Panasonic Toughbook Laptop, CF30, 2GB RAM, 1.66GHz 89 IT Core Duo, 80GB HD I Panasonic Toughbook Laptop, CF30, 2GB RAM, l .66GHz 90 IT Core Duo, 80GB HD I 91 IT Panasonic Toughbook Laptop, C1752, NO Ram 1 92 IT Panasonic Toughbook WKB3138M Keyboard - NEW l 93 IT Panasonic Toughbook WKB3138M Keyboard - NEW 1 94 IT Panasonic Toughbook WK133138M Keyboard - NEW 1 95 IT Panasonic Toughbook WKB3138M Keyboard - NEW 1 1 96 IT Panasonic Toughbook WKB3138M Keyboard -NEW 97 IT Panasonic Toughbook WKB3138M Keyboard - NEW 1 98 IT Panasonic Toughbook WK133138M Keyboard - NEW 1 99 IT Panasonic Toughbook WKB3138M Keyboard - NEW l 100 IT Panasonic Toughbook WKB3138M Keyboard - NEW l 101 IT Panasonic Toughbook WKB3138M Keyboard - NEW 1 l 02 IT Dell Power connect 5424 Switch 1 103 IT Dell Power connect 5424 Switch 1 104 Electric Adding Machine 1 105 Electric Adding Machine 1 Canvas street banners, labeled "Ashland", "Guanajuato", 106 Parks etc. I Canvas street banners, labeled "Ashland", "Guanajuato", 107 Parks etc. I Canvas street banners, labeled "Ashland", "Guanajuato", 108 Parks etc. I Canvas street banners, labeled "Ashland", "Guanajuato", 109 Parks etc. I Canvas street banners, labeled "Ashland", "Guanajuato", 110 Parks etc. I 11 ] Parks IBM Selectric Typewriter, blue 1 112 Parks Picture frames, wood. Size approx. 19 1/2 x 15 1 /2 5 113 Parks Floral design Vase I Overhead Projector, 3M, Model 1700 AJF, 4994090, 10 114 Parks 1 /2 lass I 115 Parks Wicker Basket, small, 10" diameter I 116 Parks Plastic desk trays 2 117 Parks Watering can, small, metal with fertilizer 1 118 Parks HP Printer, Model C8137A, 4SG3AC31018 1 119 Parks Metal file tray, old school vertical for desktop I 120 Parks Electric Space Heater, "Lakewood" I 121 Parks Hobart meat slicer, Model 512, #37-111-950\ 1 122 Parks Eureka a ri ht vacuum, "The Boss" 1 123 Parks Wooden book shelf, 32x24x26 height I Page 5 of 6 S11 CITY OF .SHLAND LOT # DEPT DESCRIPTION QUANTITY 124 Parks Table, Square 30" 1 125 Parks File Cabinet, 4 drawer, metal 1 126 Parks Small Refrigerator, GE 1 127 Parks JVC TV, 27", 4AV-27533 1 128 Parks Magnavox TV, 32", 9YA1 A0406027515 1 129 Parks DVD/VCR Player, 4C41A41291, unknown make 1 130 Parks Audio/Visual cart, metal, 3 shelves, 25x30x49 height I Note: Miscellaneous low dollar items no longer of value to the City and held in storage for the sealed bid auction will be logged and tagged when the items are transported from storage and staged on sight for the sealed bid auction. Pa e 6 of 6 r1praINS-11 CITY OF ASHLAND Council Communication June 2, 2015, Business Meeting Mayoral Appointment of Rich Rosenthal as Council Liaison to the Amigo Club FROM: John Stromberg, Mayor, john@council.ashland.or.us SUMMARY This is the approval of Mayoral appointment of Rich Rosenthal as Council Liaison to the Amigo Club. This appointment would be effective immediately. BACKGROUND AND POLICY IMPLICATIONS: The City of Ashland has been in a Sister City relationship with the City of Guanajuato, Mexico for over 40 years. For the last several years the Amigo Club, a non-profit community organization, has taken on much of the responsibility of maintaining and growing that relationship. Recently, the City of Ashland has agreed to become a municipal member of the Amigo Club, and pay $2,000 per year in membership fees. These fees will support the Amigo Club activities, particularly in relation to the annual 4r" of July visits to Ashland of Guanajuato representatives. With this new municipal membership, the Amigo Club has agreed to a new Council liaison to assist in the planning and execution of Sister City related activities. COUNCIL GOALS SUPPORTED: N/A FISCAL IMPLICATIONS: None STAFF RECOMMENDATION AND REQUESTED ACTION: None. SUGGESTED MOTION: I move to approve Rich Rosenthal as Council Liaison to the Amigo Club. ATTACHMENTS: None. Page 1 of 1 Dave Kanner Subject: FW: Draft CC Amigo Club Liaison From: Betzabe Turner [ ] Sent: Wednesday, May 27, 2015 12:47 PM To: 'John Stromberg'; 'Rich Rosenthal' CC: 'Dave Kanner'; 'Diana Shiplet' Subject: RE: Draft CC Amigo Club Liaison 1 CITY OF -ASHLAND Council Communication June 2, 2015, Business Meeting Confirmation of Mayoral Appointment of Tighe O'Meara as Police Chief FROM: Dave Kanner, City Administrator, kannerdgashland.or.us SUMMARY The Mayor intends to appoint Tighe O'Meara as Ashland's Police Chief and seeks Council confirmation of that appointment, as required by the City Charter. O'Meara has been Ashland's deputy police chief since January 2014 and has been serving as the City's interim chief since April 17, when former police chief Terry Holderness retired. The city conducted an open and competitive national recruitment for the police chief position, drawing 42 applications from candidates in 20 different states and two from candidates residing outside the United States. Applications were screened by Chief Holderness, me and Human Resources Manager Tina Gray and six candidates were selected for preliminary screening interviews, which were conducted by Chief Holderness. As the screening continued, it became clear that none of the candidates from outside the area were as competitive as Deputy Chief O'Meara. BACKGROUND AND POLICY IMPLICATIONS: Former Police Chief Terry Holderness gave the City notice of his intent to retire on April 17, 2015. The City completed a national search for a successor Chief and received a number of qualified applications. Among the most qualified was Ashland's Deputy Chief, Tighe O'Meara. The City conducted a national search for a new police chief, with targeted outreach to women and minority candidates. However, of the applications received, few applicants had taken the time to research Ashland and an equally small number could match the qualifications of Deputy Chief O'Meara. Preliminary screen interviews were conducted by Chief Holderness with a half dozen candidates and on the basis of those interviews, I recommended to the Mayor that he appoint O'Meara as Ashland's next Chief of Police. At the Mayor's request, the Council interviewed Chief O'Meara in an executive session on May 18, at which time the Council expressed its general support for his appointment as Police Chief. The position of Police Chief is a key role in the community. It requires an individual with a rare combination of skills and experience to provide executive leadership to a professional law enforcement staff and ensure the department delivers public safety services in a manner consistent with core values and expectations of the community. Page 1 of 2 RE CITY OF ASHLAND With almost 23 years in law enforcement, Tighe has worked for seven police agencies ranging from a very small rural community with a population of approximately 1,600 to a department in the heart of a large metro area with a population over 3,000,000. It is that wide range of experience that allowed Tighe to actively pursue Ashland as a place he wanted to live and work. Tighe joined the Ashland Police Department in 2010 and since then he has served in a variety of leadership roles including Sergeant, Deputy Chief, and most recently Interim Police Chief. Tighe holds as a Master's degree in Management, a Bachelor's degree in Psychology and has participated in numerous police executive training courses including: California Police Chiefs Association Role of the Chief, 2013, International Association of Chiefs of Police Leadership for Police Organizations, 2010, Oregon Executive Development Institute, and he has plans to attend the Senior Management Institute for Police with an anticipated graduation in June 2015. Tighe has been serving as Interim Police Chief since Chief Holderness's retirement in April. He is excited to take the next step in his career and further partnerships in a community he loves. Tighe has the full support of the staff in the Ashland Police Department as he makes the transition to Police Chief. FISCAL IMPLICATIONS: Funds are budgeted and appropriated in FY 2015 for this position. STAFF RECOMMENDATION AND REQUESTED ACTION: Staff recommends Council confirm the Mayor's appointment of Tighe O'Meara as Police Chief. SUGGESTED MOTIONS: I move confirmation of the Mayor's appointment of Tighe O'Meara as Police Chief. ATTACHMENTS: Employment Contract Page 2 of 2 CITY OF ASHLAND Employment Agreement Police Chief THIS AGREEMENT, made and entered into this 2nd day of June 2015 by and between the City of Ashland ("City") and Tighe O'Meara ("Employee"). RECITALS A. City desires to employ the services of Employee as the Police Chief of the City of Ashland; and, B. It is the desire of the City to establish certain conditions of employment for Employee; and, C. It is the desire of the City to (1) secure and retain the services of Employee and to provide inducement for Employee to remain in such employment, (2) to make possible full work productivity by assuming Employee's morale and peace of mind with respect to future security, (3) to act as a deterrent against malfeasance or dishonesty for personal gain on the part of Employee; and, (4) to provide a just means for terminating Employee's services at such time as Employee may be unable fully to discharge Employee's duties due to disability or when City may otherwise desire to terminate Employee's services; and, D. Employee desires to accept employment as Police Chief of the City of Ashland, and to begin his employment June 2, 2015. City and Employee agree as follows: Section 1. Duties. The City hereby agrees to employ Tighe O'Meara as the Police Chief of the City of Ashland to perform the functions and duties specified in the City Charter, City Ordinances, and the job description for the position, and to perform such other legally and ethically permissible and proper duties and functions as the Mayor and/or City Council shall from time to time assign. The Police Chief shall devote full time to the performance of his duties. Section 2. Term. A. Nothing in this agreement shall prevent, limit, or otherwise interfere with the right of the Mayor, with the consent of the City Council in accordance with the City Charter, from terminating the services of the Police Chief at any time, subject only to the provisions set forth in the section titled "Severance pay" of this agreement. Except as specifically provided in this Agreement, Employee shall serve at the pleasure of the City, without any requirement to demonstrate cause for dismissal. B. Nothing in this agreement shall prevent, limit, or otherwise interfere with the right of the Employee to resign at any time from his position with the City, subject only to the provisions of this agreement. C. Employee agrees to remain in the employ of the City until June 1, 2018, and neither to accept other employment nor to become employed by any other employer until this termination date, unless the termination date is affected as otherwise provided in this agreement. This provision shall not restrict Employee from using vacation or personal leave for teaching, consulting or other activities provided these activities do not conflict with the regular duties of the Employee and are approved in writing by the Mayor, with the consent of the City Council. D. In the event written notice is not given by either party to terminate this agreement at least ninety (90) days prior to the termination date, this agreement shall be extended for successive three-year periods on the same terms and conditions provided herein. E. In the event Employee wishes to voluntarily resign the position during the term of this agreement, Employee shall be required to give the City thirty (30) days written notice of such intention, unless such notice is waived by the Mayor, with consent of the City Council. Employee will cooperate in every way with the smooth and normal transfer to the newly appointed individual. Section 3. Salary Beginning June 2, 2015, City agrees to pay Employee a monthly salary at step D of the salary schedule ($9,080.64/month). Employee will advance to the next step ($9,534.68/month) after one year of successful performance as determined by the City Administrator. The City agrees to annually increase the monthly salary and/or benefits in the same percentage as may be accorded other department heads. Section 4. Performance Evaluation. The City Administrator shall review and evaluate the performance of the employee at least once annually. Employee shall receive a written copy of the performance evaluation and be provided an adequate opportunity for the employee to discuss the details of the evaluation. Section 5. Hours of Work. It is recognized that Employee must devote a great deal of time outside the normal office hours to the business of the City, and to that end Employee will be allowed to take compensatory time off as Employee shall deem appropriate during normal office hours, so long as the business of the City is not adversely affected. Work in excess of forty (40) hours per week is deemed part of the professional responsibility for which the Employee shall not be paid overtime. In recognition of the extra hours required of the Police Chief, Employee shall receive forty (40) hours of administrative leave each year to be used before June 30th or deemed forfeited. Employee will receive additional administrative leave if granted by the City Council in the Management Resolution adopted each year. Section 6. Automobile. Employee's duties require that Employee shall have the use of a motor vehicle at all times during employment with the City. The City shall provide an official police vehicle for the employee's exclusive use. City shall be responsible for paying for insurance, operation, maintenance and repairs of the vehicle. Section 7. Health, Welfare and Retirement. Except as modified by this agreement, Employee shall be entitled to receive the same retirement, vacation, sick leave benefits, holidays, and other fringe benefits and working conditions as they now exist or may be amended in the future, as apply to any other department head, as spelled out in the City's Management Resolution in addition to any benefits enumerated specifically for the benefit of Employee as provided in this agreement. Section 8. Dues and Subscriptions. City agrees to budget and to pay for the professional dues and subscriptions of Employee necessary for the continuation and full participation in national, regional, state and local associations and organizations necessary and desirable for Employee's continued professional, growth and advancement, and for the good of the City. Section 9. Professional Development The City hereby agrees to annually budget and allocate sufficient funds to pay necessary travel and living expenses of the Police Chief while he represents the City at conferences, trainings, official business meetings or professional organizations that serve the City's interest and/or are reasonably necessary to provide for the professional advancement of the Police Chief. Membership on any national or state commission or committee shall be subject to the approval of the City Administrator. Section 10. Professional Liability ` The City agrees that it shall defend, hold harmless, and indemnify the Police Chief from all demands, claims, suits, actions, errors, or other omissions in legal proceedings brought against the Police Chief in his individual capacity or in his official capacity, provided the incident arose while the Police Chief was acting within the scope of his employment. If in the good faith opinion of the Police Chief conflict exists as regards to the defense of any such claim between the legal position of the city and the Police Chief, he may engage counsel in which event, the City shall indemnify the Police Chief for the cost of legal counsel. Section 11. Severance Pay A. In the event Employee is dismissed during the term of this Agreement, and Employee is not being dismissed for any reason set forth in paragraphs B or C of this section, the City agrees to offer Employee a severance agreement. The amount of severance pay to be offered to Employee in the severance agreement shall be equal to the employee's monthly base salary at the time of dismissal; times the number of months that employee has been employed up to a maximum of six (6) months. In addition, the severance agreement offered to the employee will require the City to continue to pay the employer portion of the premium for medical and dental insurance coverage through the end of the month the Employee's severance pay is intended to cover or until the last day of the month in which Employee obtains employment with alternative insurance whichever occurs earlier. As a condition of the severance offer, the Employee will be required to release the City, its officers, representatives, insurers, and employees from claims arising from employment with the City and separation of employment. B. Employee will not be eligible to receive the severance offer described in Paragraph A of this section if this Agreement is not renewed by the City, as provided in Section 2, above. Employee also will not be eligible to receive the severance agreement offer if Employee breaches any provision of this agreement, or if Employee engages in any act of misconduct in the performance of duties on behalf of the City. The term "misconduct" includes misappropriation, dishonesty, breach of trust, insubordination, neglect of duty, failure to perform duties in a manner that is consistent with applicable law, failure to correct performance deficiencies identified in writing by the City Council after a reasonable opportunity, as determined by the City, to correct the deficiencies; committing any violation of City policies or standards that the City deems a serious violation; or engaging in other action demonstrating a disregard for the interest of the City. The term "misconduct" also includes engaging in criminal acts or other off-duty behavior that the City views as impairing the Employee's ability to effectively perform the Employee's duties or jeopardize the reputation of the City. C. Employee will not be eligible to receive the severance offer described in Paragraph A of this Section if Employee, in accordance with applicable law, is dismissed due to a disability that prevents Employee from performing the duties of the position. Section 12. Other Terms and Conditions of Employment City shall by amendments to this agreement, fix such other terms and conditions of employment from time to time , as it may determine, relating to the performance-by Employee with the agreement of Employee, provided such terms and conditions are not inconsistent or in conflict with the provisions of this agreement. Section 13. Severability. In any part, term, or provision of this agreement is held by the courts to be illegal or in conflict with the laws of the State of Oregon, the validity of the remaining portions of the agreement shall not be affected and the rights and obligations of the parties shall be construed and enforced as if the agreement did not contain the particular part, term, or provision. Section 14. Other Terms and Conditions of Employment The Employee is subject to all personnel policies of the City of the City and the City's Management Resolution except to the extent that they are inconsistent with an expressed term of this agreement. Section 15. PERS Pick-up Employee contributions to the Public Employees' Retirement system (PERS) shall be "picked up" by the City. Employee shall not have the option of receiving money designated for retirement contributions and directly making the contribution to PERS. Employee's reported salary for tax purposes shall be reduced by the amount of the employee's contribution to PERS. Section 16. Complete Agreement This agreement shall constitute the entire agreement between the City and Employee and supersedes all prior agreements, representations and understandings between them. No supplement, modification or amendment of this Agreement shall be binding on the City unless it is set forth in a writing that is signed by the Mayor and approved by the City Council. Likewise, no waiver or any provision of this Agreement shall be valid unless set forth in writing that is signed by the Mayor and approved by the City Council. Dated this day of June 2015 John Stromberg Mayor Accepted this day of May 2015 Tighe O'Meara Attest: Barbara Christensen City Recorder CITY OF SHLAND Council Communication June 2, 2015, Business Meeting Adoption of the City's self-insured health plan for the plan year July 1, 2015 through June 30, 2016. FROM Dave Kanner, City Administrator, dave.kanner a,ashland.or.us Tina Gray, Human Resources Manager, tina.gray2ashland.or.us SUMMARY The Employee Health Benefits Advisory Committee recommends that the City Council adopt the City's existing self-insured health plan with modifications required by the Affordable Care Act and the State of Oregon, but with no other changes. BACKGROUND AND POLICY IMPLICATIONS: July 1, 2013, the City transitioned from a fully-insured health plan with PacificSource, to a self-insured health plan (medical, dental and vision). The City retained PacificSource as its third party claims administrator so the change in claim processing would be imperceptible by employees. The City established an Employee Health Benefits Advisory Committee (EHBAC), composed of representatives from each bargaining group as well as the non-represented City and Parks employees. The charge of the EHBAC is to meet regularly and review claims experience and make recommendations for the upcoming plan year. This year the committee's only recommendation is to incorporate changes required by the Affordable Care Act and the State of Oregon into the health plan for compliance. The Affordable Care Act changes, are administrative in nature and relate to the definition of full-time employee and new hire eligibility. These changes do not have a substantive effect on the plan. The one change required by state legislation that materially affects the plan is a mandate to provide certain coverage without cost-sharing for women with diabetes during pregnancy. FISCAL IMPLICATIONS: The full cost of the health benefits plan, funded by a per-FTE charge to City departments and an employee premium contribution is included in the approved BN 2015-17 budget. Effective July 1, 2015, the City will increase its per-FTE charge and premium equivalent by 16.3% to cover the projected increases in utilization and fixed administrative costs. All city employees pay 5% of premium for their coverage, so the net cost of the 5% share will increase as well. Thanks to the City's efforts over the past few years to control healthcare costs, this is the first increase in premiums since 2012. STAFF RECOMMENDATION AND REQUESTED ACTION: Staff recommends approval of the 2015-2016 City of Ashland Self-insured health plan with revised appeal language and Administrative changes required by the Affordable Care Act. Page I of 2 WAN CITY OF -,S H LA D SUGGESTED MOTION: I move approval of the 2015-2016 City of Ashland self-insured health benefit plan. ATTACHMENTS: Prior year health plan summary City Prior year health plan summary Parks Modifications required under the Affordable Care Act Page 2 of 2 IrPTAWA CITY OF ANL..J► City of Ashland Group No.: 00032482 Preferred 90+200 VAR GF 0812 Effective: July 1, 2014 Third Party Administrative Services Provided By: PSPD 0714_City of Ashland V2 091614 SingleSource Self- Insured This page left intentionally blank. SPD 0714 City of Ashland V2 091614 II INTRODUCTION Welcome to your City of Ashland (also referred to as `the employer' or `employer) group health plan. Your employer offers this coverage to help you and your family members stay well, and to protect you in case of illness or injury. Your plan includes a wide range of benefits and services, and PacificSource hopes you will take the time to become familiar with them. Your employer, who is also the Plan Sponsor, has prepared this document to help you understand how your plan works and how to use it. This document summarizes the benefits provided under the Preferred 90+200 VAR GF 0812 Plan (referred to as `the plan' or `this plan' throughout this document). Please read it carefully and thoroughly. Your benefits are affected by certain limitations and conditions, which require you to be a wise consumer of health services and to use only those services you need. Also, benefits are not provided for certain kinds of treatments or services, even if your health care provider recommends them. The plan is a self-insured medical plan intended to meet the requirements of Sections 105(b), 105(h), and 106 of the Internal Revenue Code so that the portion of the cost of coverage paid by your Plan Sponsor, and any benefits received by you through this plan, are not taxable income to you. Your specific tax treatment will depend on your personal circumstances; the plan does not guarantee any particular tax treatment. You are solely responsible for any and all federal, state, and local taxes attributable to your participation in this plan, and the plan expressly disclaims any liability for such taxes. The plan is 'self-insured,' which means benefits are paid from your employer's general assets and or trust funds and are not guaranteed by an insurance company. The Plan Sponsor has contracted with a Third Party Administrator to perform certain administrative services related to this plan. PacificSource Health Plans is the Third Party Administrator and provides administrative services for this plan on behalf of the Plan Sponsor. If anything is unclear to you, PacificSource's staff is available to answer your questions. Please give them a call or visit them on the Internet at PacificSource.com. PacificSource looks forward to serving you and your family. PacificSource Health Plans PO Box 7068, Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 Espanol (800) 624-6052, extension 1009 cs@pacificsource.com This document serves as the written Plan document and Summary Plan Description (SPD). It is very important that you review the entire document carefully to confirm a complete understanding of the benefits available, as well as your responsibility, under the plan. This document is written in simple, easy-to-understand language. Technical terms are printed in italics and defined in the Plan Terms and Definitions section. This document explains the services covered by the plan; the benefit summaries tell you how much this plan pays toward expenses and amounts for which you are responsible. As used in this document, the word `year' refers to the benefit year, which is the 12-month period beginning January 1 and ending December 31. The word lifetime as used in this document refers to the period of time you or your eligible dependents participate in this plan or any other plan sponsored by the Plan Sponsor. Any amount you or your eligible dependents have accumulated toward the benefit maximum amounts, deductible, or out-of-pocket maximum of any immediately prior plan sponsored by the Plan Sponsor will be counted toward the benefit maximum amounts of this plan. The Plan Sponsor reserves the right to amend, modify, or terminate this plan in any manner, at any time, which may result in termination or modification of your coverage. If this plan is terminated, any plan assets will be used to pay for eligible expenses incurred prior to the plan's termination, and such expenses will be paid as provided under the terms of this plan prior to termination. If there is any conflict between this document and the underlying plan document(s), the plan document(s) control. SPD 0714_City of Ashland V2 091614 III This page left intentionally blank. SPD 0714_City of Ashland V2 091614 IV CONTENTS MEDICAL BENEFIT SUMMARY 3 PRESCRIPTION BENEFIT SUMMARY 5 CHIROPRACTIC CARE BENEFIT SUMMARY 10 ADDITIONAL ACCIDENT BENEFIT SUMMARY 12 VISION BENEFIT SUMMARY ......................................................................................14 DENTAL BENEFIT SUMMARY 18 USING THE PROVIDER NETWORK 20 Preferred Provider Organization (PPO) 20 What is a PPO .......................................................................................................................................20 Who is Your PPO ...................................................................................................................................20 About Your PPO 20 Non-PPO Providers 21 Example of Provider Payment 21 Allowable Amount 21 NETWORK NOT AVAILABLE BENEFITS 21 COVERAGE WHILE TRAVELING 21 Nonemergency Care While Traveling ....................................................................................................22 Emergency Services While Traveling 22 FINDING PARTICIPATING PROVIDER INFORMATION 22 TERMINATION OF PROVIDER CONTRACTS 22 BECOMING ELIBIGLE .................................................................................................23 Who Pays for Your Benefits 23 Who is Eligible .......................................................................................................................................23 ENROLLING DURING THE INITIAL ENROLLMENT PERIOD 24 Newborns 24 Adopted Children ...................................................................................................................................24 Foster Children ......................................................................................................................................24 Family Members Acquired by Marriage .................................................................................................24 Family Members Acquired by Domestic Partnership .............................................................................25 Family Members Placed in Your Guardianship 25 Qualified Medical Child Support Orders 25 ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD 25 Returning to Work after a Layoff ............................................................................................................25 Returning to Work after a Leave of Absence 25 Returning to Work after Family Medical Leave ......................................................................................26 Special Enrollment Periods ....................................................................................................................26 Dental Enrollment 26 Late Enrollment ......................................................................................................................................26 Member ID Card ....................................................................................................................................27 PLAN SELECTION PERIOD 27 TERMINATING COVERAGE 27 Divorced Spouses ..................................................................................................................................27 Dependent Children ...............................................................................................................................27 Dissolution of Domestic Partnership ......................................................................................................27 Certificates of Creditable Coverage .......................................................................................................28 SPD 0714-City of Ashland V2 091614 v CONTINUATION OF COVERAGE 28 USERRA CONTINUATION 28 Surviving or Divorced Spouses and Qualified Domestic Partners .........................................................28 COBRA CONTINUATION 29 COBRA Eligibility 29 When Continuation Coverage Ends ......................................................................................................29 Type of Coverage 29 Your Responsibilities and Deadlines 30 Continuation Premium 30 Keep Your Plan Informed of Address Changes 30 CONTINUATION WHEN YOU RETIRE 30 WORK STOPPAGE 31 Labor Unions ..........................................................................................................................................31 COVERED EXPENSES 31 Medical Necessity ..................................................................................................................................31 Healthcare Providers 31 Your Annual Out-of-Pocket Limit 32 MEDICAL BENEFITS 32 About Your Medical Benefits 32 PLAN BENEFITS 33 PREVENTIVE CARE SERVICES 34 PROFESSIONAL SERVICES 36 HOSPITAL AND SKILLED NURSING FACILITY SERVICES 37 OUTPATIENT SERVICES 37 EMERGENCY SERVICES 38 MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES 39 Mental Health and Chemical Dependency Services 39 Medical Necessity and Appropriateness of Treatment ..........................................................................40 HOME HEALTH AND HOSPICE SERVICES 40 DURABLE MEDICAL EQUIPMENT 41 TRANSPLANT SERVICES 42 Payment of Transplant Benefits 43 OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS 43 BENEFIT LIMITATIONS AND EXCLUSIONS 46 Least Costly Setting for Services ...........................................................................................................46 EXCLUDED SERVICES 46 A Note About Optional Benefits .............................................................................................................46 Experimental or Investigational Treatment ............................................................................................50 EXCLUSION PERIODS 52 Exclusion Period for Transplant Benefits 52 CREDIT FOR PRIOR COVERAGE 52 Evidence of Prior Creditable Coverage 52 SPD 0714_City of Ashland V2 091614 vi HEALTH CARE MANAGEMENT AND PREAUTHORIZATION 53 What is Health Care Management ........................................................................................................53 Case Management .................................................................................................................................54 Individual Benefits Management ............................................................................................................54 HOW TO USE YOUR DENTAL PLAN 54 DENTAL PLAN BENEFITS 54 COVERED DENTAL SERVICES 55 Class I Services - Diagnostic and Preventive Treatment 55 Class II Restorative Services - Basic and Restorative Treatment 55 Class II Complicated Services - Complicated Treatment 56 Class I I I Services - Major Treatment 56 EXCLUDED DENTAL SERVICES 57 CLAIMS PROCEDURES 59 Questions about Your Claims 59 Types of Claims 60 How to File a Claim ................................................................................................................................60 Incomplete Claims .................................................................................................................................62 Notification of Benefit Determination .....................................................................................................62 Adverse Benefit Determination ..............................................................................................................63 Your Right to Appeal ..............................................................................................................................63 Resources For Information And Assistance ..........................................................................................66 Plan Sponsor's Discretionary Authority; Standard of Review 67 Coordination of Benefits .........................................................................................................................67 Order of Payment When Coordinating with Other Group Health Plans ................................................68 OTHER IMPORTANT PLAN PROVISIONS 69 Assignment of Benefits 69 Proof of Loss ..........................................................................................................................................69 No Verbal Modifications of Plan Provisions ...........................................................................................69 Reimbursement to the Plan 70 Subrogation 70 Recovery of Excess Payments 71 Right To Receive and Release Necessary Information .........................................................................71 Reliance on Documents and Information ...............................................................................................71 No Waiver 71 Physician/Patient Relationship 72 Plan not responsible for Quality of Health Care ....................................................................................72 Plan is not a Contract of Employment 72 Right to Amend or Terminate Plan ........................................................................................................72 Applicable Law .......................................................................................................................................72 PRIVACY AND CONFIDENTIALITY 72 Permitted Disclosures of Protected Health Information to the Plan Sponsor ........................................73 No Disclosure of Protected Health Information to the Plan Sponsorwithout Certification by Plan Sponsor 73 Conditions of Disclosure of Protected Health Information to the Plan Sponsor ....................................73 Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the Plan Sponsor 73 Required Separation between the Plan and the Plan Sponsor .............................................................74 DEFINITIONS 74 RIGHTS OF PLAN MEMBERS 83 SPD 0714_City of Ashland V2 091614 VII This page left intentionally blank. SPD 0714-City of Ashland V2 091614 VIII Grandfathered Health Plan The Plan Sponsor believes this plan is a `grandfathered health plan' under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Plan Sponsor, or you may contact PacificSource at: PacificSource Health Plans PO Box 7068 Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 email: cs@pacificsource.com SPD 0714_City of Ashland V2 091614 1 This page left intentionally blank. SPD 0714_City of Ashland V2 091614 2 MEDICAL BENEFIT SUMMARY POLICY INFORMATION Group Name: City of Ashland Group Number: G0032482 Plan Name: Preferred 90+200 VAR GF 0812 Provider Network: Preferred PSN EMPLOYEE ELIGIBILITY REQUIREMENTS Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours Waiting Period for New Employees: 1st day of the month following one (1) day. A person hired on the first day of the month is eligible on the first day of the following month. ANNUAL DEDUCTIBLE ..........................................$200 per person / $600 per family The deductible is an amount of covered medical expenses the member pays each benefit year before the plan's benefits begin. The deductible applies to all services and supplies except those marked with an asterisk Once a member has paid a total amount toward covered expenses during the benefit year equal to the per person amount listed above, the deductible will be satisfied for that person for the rest of that benefit year. Once any covered family members have paid a combined total toward covered expenses during the benefit year equal to the per family amount listed above, the deductible will be satisfied for all covered family members for the rest of that benefit year. Deductible expense is not applied to the out-of-pocket limit. ANNUAL OUT-OF-POCKET LIMIT Participating Providers $700 per person / $1,400 per family Non-participating Providers $1,700 per person / $3,400 per family Only participating provider expense applies to the participating provider out-of-pocket limit and only non- participating provider expense applies to the non-participating out-of-pocket limit. Once the participating provider out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the co-payment is deducted) for participating and network not available providers for the rest of that benefit year. Once the non-participating provider out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the co-payment is deducted) for non-participating providers for the rest of that benefit year. Deductibles, co-payments, transplants performed at a non-participating facility, benefits paid in full and non-participating provider charges in excess of the allowable fee do not accumulate toward the out-of-pocket limit. Co-payments and non-participating provider charges in excess of the allowable fee will continue to be the member's responsibility even after the out-of-pocket limit is met. ADDITIONAL ACCIDENT BENEFIT The first $1,000 of covered expenses within 90 days of an accident is covered at no charge and is not subject to the deductible. The balance is covered as shown below. The member is responsible for the above deductible and the following co-payments and co-insurance. PARTICIPATING PROVIDERS/ NON-PARTICIPATING SERVICE: NETWORK NOT AVAILABLE: PROVIDERS: PREVENTIVE CARE Well Baby/Well Child Care 10% co-insurance 30% co-insurance Routine Physicals No charge* No charge` Well Woman Visits No charge* No charge* Immunizations - 0-18 yrs No charge* No charge* Immunizations - age 19 and over 10% co-insurance 30% co-insurance Colonoscopy 10% co-insurance 30% co-insurance PROFESSIONAL SERVICES Office and Home Visits 10% co-insurance 30% co-insurance Office Procedures and Supplies 10% co-insurance 30% co-insurance Surgery 10% co-insurance 30% co-insurance Outpatient Rehabilitation Services 10% co-insurance 10% co-insurance HOSPITAL SERVICES Inpatient Room and Board 10% co-insurance 30% co-insurance Inpatient Rehabilitation Services 10% co-insurance 30% co-insurance Skilled Nursing Facility Care 10% co-insurance 30% co-insurance SPD 0714_City of Ashland V2 091614 3 OUTPATIENT SERVICES Outpatient Surgery/Services 10% co-insurance 30% co-insurance Advanced Diagnostic Imaging 10% co-insurance 30% co-insurance Diagnostic and Therapeutic Radiology 10% co-insurance 30% co-insurance and Lab URGENT AND EMERGENCY SERVICES Urgent Care Center Visits 10% co-insurance 30% co-insurance Emergency Room Visits $100 co-pay/visit plus $100 co-pay/visit plus 10 /o co-insurance 10/o co-insurance Ambulance, Ground 10% co-insurance 10% co-insurance Ambulance, Air 10% co-insurance 10% co-insurance MENTAL HEALTH/CHEMICAL DEPENDENCY SERVICES Office Visits 10% co-insurance 30% co-insurance Inpatient Care 10% co-insurance 30% co-insurance Residential Programs 10% co-insurance 30% co-insurance OTHER COVERED SERVICES Allergy Injections 10% co-insurance 30% co-insurance Durable Medical Equipment 10% co-insurance 30% co-insurance Home Health Care 10% co-insurance 10% co-insurance Chiropractic Plus (12 visits/benefit 10% co-insurance 10% co-insurance year) A For emergency medical conditions, non-participating providers are paid at the participating provider level. Not subject to annual deductible. Payment to providers is based on the prevailing or contracted PacificSource fee allowance for covered services. Although participating providers accept the fee allowance as payment in full, non-participating providers may not. Services of non- participating providers could result in out-of-pocket expense in addition to the cost share above. Network Not Available (NNA) payment is allowed when PacificSource has not contracted with providers in the geographical area of the member's residence or work for a specific service or supply. Payment to providers for NNA is based on the usual, customary, and reasonable charge for the geographical area in which the charge is incurred. SPD 0714_City of Ashland V2 091614 4 PRESCRIPTION BENEFIT SUMMARY Your Plan Sponsor's health plan includes coverage for prescription drugs and certain other pharmaceuticals, subject to the information below. Your prescription drug plan qualifies as creditable coverage for Medicare Part D. PRESCRIPTION DRUG OUT-OF-POCKET LIMIT $2,500 The co-payment and/or co-insurance for prescription drugs obtained from a participating pharmacy is waived at participating pharmacies during the remainder of a benefit year in which you have satisfied a Prescription Drug Out of Pocket Limit of $2,500. The limit applies to each member. Claims must be submitted by the participating pharmacy electronically. Differential between brand name and generic drugs, and drugs obtained at a non-participating pharmacy do not apply toward the limit. MEMBER COST SHARE (other than for Specialty Drugs) Effective July 1, 2014 - September 30, 2014 Each time a covered pharmaceutical is dispensed, you are responsible for the co-payment and/or co- insurance below: Tier 1: Tier 2: Tier 3: Generic Preferred Non-preferred From a participating retail pharmacy using the PacificSource Pharmacy Program (see below): Up to a 34-day supply: $5 $25 $50 From a participating mail order service (see below): Up to a 34-day supply: $5 $25 $50 35 to 90-day supply: $10 $50 $100 From a participating retail pharmacy without using Not covered, the PacificSource Pharmacy Program, or from a except 5-day emergency supply non-participating pharmacy (see below): MEMBER COST SHARE (other than for Specialty Drugs) Effective October 1, 2014 - June 30, 2015 Each time a covered pharmaceutical is dispensed, you are responsible for the co-payment and/or co- insurance below: Tier 1: Tier 2: Tier 3: Generic Preferred Non-preferred From a participating retail pharmacy using the PacificSource Pharmacy Program (see below): Up to a 34-day supply: $5 $25 $50 35 to 60-day supply: $10 $50 $100 61 to 94- day supply: $15 $75 $150 From a participating mail order service (see below): Up to a 34-day supply: $5 $25 $50 35 to 94-day supply $10 $50 $100 SPD 0714_City of Ashland V2 091614 5 From a participating retail pharmacy without using Not covered, the PacificSource Pharmacy Program, or from a except 5-day emergency supply non-participating pharmacy (see below): MEMBER COST SHARE FOR SPECIALTY DRUG Each time a covered specialty drug is dispensed, you are responsible for the co-payment and/or co- insurance below: From the participating specialty pharmacy: Up to a 30-day supply: Same as retail pharmacy co-payment above From a participating retail pharmacy, from a participating mail order service, or from a non- Not covered, participating pharmacy or pharmaceutical service except 5-day emergency supply provider: WHAT HAPPENS WHEN A BRAND NAME DRUG IS SELECTED Regardless of the reason or medical necessity, if you receive a brand name drug or if your physician prescribes a brand name drug when a generic is available, you will be responsible for the brand name drug's co-payment and/or co-insurance. USING THE PACIFICSOURCE PHARMACY PROGRAM Retail Pharmacy Network To use the PacificSource pharmacy program, you must show the pharmacy plan number on the PacificSource ID card at the participating pharmacy to receive your plan's highest benefit level. When obtaining prescription drugs at a participating retail pharmacy, the PacificSource pharmacy program can only be accessed through the pharmacy plan number printed on your PacificSource ID card. That plan number allows the pharmacy to collect the appropriate co-payment and/or co-insurance from you and bill PacificSource electronically for the balance. Mail Order Service This plan includes a participating mail order service for prescription drugs. Most, but not all, covered prescription drugs are available through this service. Questions about availability of specific drugs may be directed to the PacificSource Customer Service Department or to the plan's participating mail order service vendor. Forms and instructions for using the mail order service are available from PacificSource and on PacificSource's website, PacificSource.com. Specialty Drug Program PacificSource contracts with a specialty pharmacy services provider for high-cost injectable medications and biotech drugs. A pharmacist-led CareTeam provides individual follow-up care and support to covered members with prescriptions for specialty medications by providing them strong clinical support, as well as the best drug pricing for these specific medications and biotech drugs. The CareTeam also provides comprehensive disease education and counseling, assesses patient health status, and offers a supportive environment for patient inquiries. Participating provider benefits for specialty drugs are available when you use PacificSource's specialty pharmacy services provider. Specialty drugs are not available through the participating retail pharmacy network or mail order service. More information regarding PacificSource's exclusive specialty pharmacy services provider and health conditions and a list of drugs requiring preauthorization and/or are subject to pharmaceutical service restrictions is on PacificSource's website, PacificSource.com. OTHER COVERED PHARMACEUTICALS Supplies covered under the pharmacy plan are in place of, not in addition to, those same covered supplies under the medical plan. Member cost share for items in this section are applied on the same basis as for other prescription drugs, unless otherwise noted. Diabetic Supplies SPD 0714_City of Ashland V2 091614 6 • Insulin, diabetic syringes, lancets, and test strips are available. • Glucagon recovery kits are available for the plan's preferred brand name co-payment. • Glucostix and glucose monitoring devices are not covered under this pharmacy benefit, but are covered under the medical plan's durable medical equipment benefit. Contraceptives • Oral contraceptives • Implantable contraceptives, contraceptive injections, contraceptive patches, and contraceptive rings are available. • Diaphragm or cervical caps are available. Tobacco Cessation Program specific tobacco cessation medications are covered with active participation in a plan approved tobacco cessation program (see Preventive Care in the policy's Covered Expenses section). Orally Administered Anticancer Medications Orally administered anticancer medications used to kill or slow the growth of cancerous cells are available. Co-payments for orally administered anticancer medication are applied on the same basis as for other drugs. Orally administered anticancer medications covered under the pharmacy plan are in place of, not in addition to, those same covered drugs under the medical plan. LIMITATIONS AND EXCLUSIONS • This plan only covers drugs prescribed by a licensed physician (or other licensed practitioner eligible for reimbursement under your plan) prescribing within the scope of his or her professional license, except for: - Over-the-counter drugs or other drugs that federal law does not prohibit dispensing without a prescription (even if a prescription is required under state law). - Drugs for any condition excluded under the health plan. That includes drugs intended to promote fertility, treatments for obesity or weight loss, tobacco cessation drugs (except as specifically provided for under Other Covered Pharmaceuticals), experimental drugs, and drugs available without a prescription (even if a prescription is provided). - Some specialty drugs that are not self-administered are not covered by this pharmacy benefit, but are covered under the medical plan's office supply benefit. - Immunizations (although not covered by this pharmacy benefit, immunizations may be covered under the medical plan's preventive care benefit). - Drugs and devices to treat erectile dysfunction. - Drugs used as a preventive measure against hazards of travel. - Vitamins, minerals, and dietary supplements, except for prescription prenatal vitamins and fluoride products, and for services that have a rating of `A' or `B' from the U.S Preventive Services Task Force (USPSTF). • Certain drugs require preauthorization by PacificSource in order to be covered. An up-to-date list of drugs requiring preauthorization is available on PacificSource's website, PacificSource.com. • PacificSource may limit the dispensing quantity through the consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and governmental approval status. • Effective July 1, 2014 - September 30, 2014: Quantities for any drug filled or refilled are limited to no more than a 34-day supply when purchased at retail pharmacy or a 90-day supply when purchased through mail order pharmacy service or a 30-day supply when purchased through a specialty pharmacy. • Effective October 1, 2014 - June 30, 2015: Quantities for any drug filled or refilled are limited to no more than a 94-day supply when purchased at retail pharmacy or through mail order pharmacy service or a 30-day supply when purchased through a specialty pharmacy. • For drugs purchased at non-participating pharmacies or at participating pharmacies without using the PacificSource pharmacy program, reimbursement is limited to an allowable fee. SPD 0714_City of Ashland V2 091614 7 • Non-participating pharmacy charges are not eligible for reimbursement unless you have a true medical emergency that prevents you from using a participating pharmacy. Drugs obtained at a non-participating pharmacy due to a true medical emergency are limited to a 5 day supply. • The member cost share for prescription drugs (co-payments, co-insurance, and service charges) does not apply to the medical deductible or out-of-pocket limit of the policy. You continue to be responsible for the prescription drug co-payments and service charges regardless of whether the policy's out-of-pocket limit is satisfied. • Prescription drug benefits are subject to your plan's coordination of benefits provision. (For more information see Claims Payment - Coordination of Benefits in your Summary Plan Description.) GENERAL INFORMATION ABOUT PRESCRIPTION DRUGS A drug formulary is a list of preferred medications used to treat various medical conditions. The formulary for this plan is known as the Preferred Drug List (PDL). The drug formulary is used to help control rising healthcare costs while ensuring that you receive medications of the highest quality. It is a guide for your physician and pharmacist in selecting drug products that are safe, effective, and cost efficient. The drug formulary is made up of name brand products. A complete list of medications covered under the drug formulary is available on the For Members area on PacificSource's website, PacificSource.com. The drug formulary is developed by Caremark@ in cooperation with PacificSource. Non-preferred drugs are covered brand name medications not on the drug formulary. Generic drugs are equivalent to name brand medications. By law, they must have the same active ingredients as the brand name medication and are subject to the same standards of their brand name counterpart. Name brand medications lose their patent protection after a number of years. Any drug company can then produce the drug, and the manufacturer must pass the same strict FDA standards of quality and product safety as the original manufacturer. Generic drugs are less expensive than brand name drugs because there is more competition and there is no need to repeat costly research and development. Your pharmacist and physician are encouraged to use generic drugs whenever they are available. SPD 0714 City of Ashland V2 091614 8 This page left intentionally blank. SPD 0714_City of Ashland V2 091614 9 CHIROPRACTIC CARE BENEFIT SUMMARY Your plan's chiropractic care benefit allows you to receive treatment from licensed chiropractors for medically necessary diagnosis and treatment of illness or injury. Refer to the Medical Benefit Summary for your co-payment and/or co-insurance information. PacificSource contracts with a network of chiropractors, so you can reduce your out-of-pocket expense by using one of the participating providers. For a listing of participating chiropractors in your area, please refer to your plan's participating provider directory, visit our website, Pacificsource.com, or call our Customer Service Department. Covered Services • Chiropractic manipulation, massage therapy, and any laboratory services, x-rays, radiology, and durable medical equipment provided by or ordered by a chiropractor. The combined benefit for all treatments, services, and supplies provided or ordered by a chiropractor is limited to 12 visits per person in any benefit year. Excluded Services • Any service or supply excluded or not otherwise covered by the medical plan. • Drugs, homeopathic medicines, or homeopathic supplies furnished by a chiropractor. • Services of an alternative care provider for pregnancy or childbirth. SPD 0714_City of Ashland V2 091614 10 This page left intentionally blank. SPD 0714-City of Ashland V2 091614 11 ADDITIONAL ACCIDENT BENEFIT SUMMARY In the event of an injury caused by an accident, first dollar benefits are provided for covered expenses according to the following: Related Definitions 'Accident' means an unforeseen or unexpected event causing injury that requires medical attention. 'Injury' means bodily trauma or damage which is independent of disease or infirmity. The damage must be caused solely through external and accidental means. Injury, for the purpose of this benefit, does not include musculoskeletal sprains or strains obtained in the performance of physical activity. Covered Expenses Benefits for the following covered expenses are provided, subject to the limitations stated below: • Services or supplies provided by a physician (except orthopedic braces) • Services of a hospital • Services of a registered nurse who is unrelated to the injured person by blood or marriage • Services of a registered physical therapist • Services of a physician or a dentist for the repair of a fractured jaw or natural teeth • Diagnostic radiology and laboratory services • Transportation by local ground ambulance Limitations • The treatment must be medically necessary for the injury. • The treatment or service must be provided within 90 days after the injury occurs. • The first $1,000 of covered expense is paid at 100% and is not subject to the deductible. SPD 0714_City of Ashland V2 091614 12 This page left intentionally blank. SPD 0714_City of Ashland V2 091614 13 VISION BENEFIT SUMMARY Your Plan Sponsor covers vision exams, eyeglasses, and contact lenses. The following shows the vision benefits available. Member Responsibility PARTICIPATING NON-PARTICIPATING SERVICE/SUPPLY PROVIDERS: PROVIDERS: Eye Exam for members No charge No charge up to a $71 through Age 18 maximum Eye Exam for members Age 19 No Charge No charge up to a $71 and Older maximum Hardware for members No charge for one pair per Same benefits as members through Age 18 year for non-collection Age 19 and Older frames and/or lenses Hardware for members Age 19 and Older Lenses (maximum per pair) Single Vision No charge No charge up to a $51 maximum Bifocal No charge No charge up to a $77 maximum Trifocal No charge No charge up to a $100 maximum Lenticular No charge Not covered Progressive No charge Not covered Frames No charge up to a No charge up to a $120 maximum $66 maximum Contacts (in place of glasses) No charge up to a $166 No charge up to a $166 maximum maximum The amounts listed above are the maximum benefits available for all vision exams, lenses, and frames furnished during any benefit period when prescribed by a licensed ophthalmologist or licensed optometrist. Participating providers discount hardware services. Limitations and Exclusions The out-of-pocket expense for vision services (co-payments and service charges) does not apply to the medical plan's deductible or out-of-pocket limit. Also, the member continues to be responsible for the vision co-payments and service charges regardless of whether the medical plan's out-of-pocket limit is satisfied. Benefit Limitations: enrolled members through age 18 `Collection' lenses and/or frames refers to brand name hardware when comparable non- brand/non-collection lenses and/or frames are available. Collection glasses (lenses and frames) are not covered. • One vision exam every benefit year • One pair of non-collection glasses (lenses and frames) per benefit year. If the cost of the frame is over $175, preauthorization by PacificSource is required. • In lieu of eyeglasses, elective contact lens services and materials are covered in full with the following limitations per benefit year o Standard = 1 contact lens per eye (total 2 lenses); OR o Monthly = 6 lenses per eye (total 12 lenses); OR SPD 0714_City of Ashland V2 091614 14 o Bi-weekly = 6 lenses per eye (total 12 lenses); OR o Dailies = 30 lenses per eye (total 60 lenses) Benefit Limitations: enrolled members age 19 and older • One vision exam every 24 months • Lenses: One pair every 24 months • Frames: Once every 24 months • Contact lenses: Once every 24 months • Elective contact lenses are in lieu of frames and lenses Covered expenses do not include, and no benefits are payable for: • Special procedures such as orthoptics or vision training • Special supplies such as sunglasses (plain or prescription) and subnormal vision aids • Tint • Plano contact lenses • Anti-reflective coatings and scratch resistant coatings • Separate charges for contact lens fitting • Replacement of lost, stolen, or broken lenses or frames • Duplication of spare eyeglasses or any lenses or frames • Nonprescription lenses • Visual analysis that does not include refraction • Services or supplies not listed as covered expenses • Eye exams required as a condition of employment, or required by a labor agreement or government body • Expenses covered under any worker's compensation law • Services or supplies received before this plan's coverage begins or after it ends • Charges for services or supplies covered in whole or in part under any other medical or vision benefits provided by the Plan Sponsor • Medical or surgical treatment of the eye SPD 0714-City of Ashland V2 091614 15 Important information about your vision benefits Your Plan Sponsor's health plan includes coverage for vision services, including prescription eyeglasses and contact lenses. To make the most of those benefits, it's important to keep in mind the following: • Participating Providers PacificSource is able to add value to your vision benefits by contracting with a network of vision providers. Those providers offer vision services at discounted rates, which are passed on to you in your benefits. • Paying for Services Please remember to show your current PacificSource ID card whenever you use your plan's benefits. PacificSource's provider contracts require participating providers to bill us directly whenever you receive covered services and supplies. Providers normally call PacificSource to verify your vision benefits. Participating providers should not ask you to pay the full cost in advance. They may only collect your share of the expense up front, such as co-payments and amounts over your plan's allowances. If you are asked to pay the entire amount in advance, tell the provider you understand they have a contract with PacificSource and should bill PacificSource directly. • Sales and Special Promotions Vision retailers often use coupons and promotions to bring in new business, such as free eye exams, two-for-one glasses, or free lenses with purchase of frames. Because participating providers already discount their services through their contract with PacificSource, your plan's participating provider benefits cannot be combined with any other discounts or coupons. You can use your plan's participating provider benefits, or you can use your plan's non-participating provider benefits to take advantage of a sale or coupon offer. If you do take advantage of a special offer, the participating provider may treat you as an uninsured customer and require full payment in advance. You can then send the claim to PacificSource yourself, and PacificSource will reimburse you according to your plan's non-participating provider benefits. PacificSource hopes this information helps clarify your vision benefits. If you or your provider have any questions about your benefits, please call PacificSource Customer Service at (541) 686-1242 from Eugene-Springfield or (888) 977-9299 from other areas. SPD 0714_City of Ashland V2 091614 16 This page left intentionally blank. SPD 0714_City of Ashland V2 091614 17 DENTAL BENEFIT SUMMARY POLICY INFORMATION Group Name: City of Ashland Group Number: G0032482 Plan Name: Preferred Incentive Dental $1500 VAR 0711 EMPLOYEE ELIGIBILITY REQUIREMENTS Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours Waiting Period for New Employees: 1 st day of the month following one (1) day. A person hired on the first day of the month is eligible on the first day of the following month. DENTAL BENEFIT SUMMARY Subject to all the terms of this Group Dental Policy, the Plan Sponsor will pay a dental benefit for covered dental expenses incurred by a covered person. The dental benefit is a percentage of the usual, customary, and reasonable charge for covered dental expenses incurred, subject to an annual maximum benefit, and an annual deductible, as follows: Maximum Payment The amount payable by this plan for covered services received under Class I are unlimited. The maximum amount payable by this plan for covered Class II and Class III services received each benefit year, or portion thereof, for each eligible patient is limited to $1,500. PLAN PAYMENT SCHEDULE Class I Services- Plan pays 70% toward covered Class I Services - Diagnostic and Preventive Treatment. Class II Restorative Services- Plan pays 70% toward covered Class II Restorative Services - Restorative Treatment. Class II Complicated Services- Plan pays 70% toward covered Class II Complicated Services - Complicated Treatment. Class III Services- Plan pays 70% toward covered Class III Services - Major Treatment. This plan pays the percentage indicated above toward Class I, II and III Services during the first year an individual is eligible. Payment increases 10 percent (to a maximum benefit of 100 percent) each successive benefit year for Class I, II and III Services if the member visits a dentist at least once during the benefit year. Payment decreases 10 percent (to a minimum benefit of the percentage stated above) each successive benefit year if the member does not visit a dentist at least once during the previous benefit year. SPD 0714_City of Ashland V2 091614 18 This page left intentionally blank. SPD 0714_City of Ashland V2 091614 19 USING THE PROVIDER NETWORK This section explains how your plan's benefits differ when you use participating and non-participating providers. This information is not meant to prevent you from seeking treatment from any provider if you are willing to take increased financial responsibility for the charges incurred. All healthcare providers are independent contractors. Neither your Plan Sponsor nor PacificSource can be held liable for any claim or damages for injuries you experience while receiving medical care. Preferred Provider Organization (PPO) What is a PPO A preferred provider organization (PPO) has made agreements with hospitals, physicians, practitioners, and other health care providers to discount the cost of services they provide. Who is Your PPO The Plan Sponsor has chosen PacificSource to provide PPO services for employees and eligible dependents in Oregon, Idaho, and Montana service areas and in bordering communities in southwest Washington. They also have an agreement with a nationwide provider network, The First Health@ Network. The First Health providers outside PacificSource's service area are also considered participating providers under your plan. A list of participating providers can be accessed through the PacificSource website: PacificSource.com or by calling PacificSource at (888) 977-9299. This list of participating providers is updated regularly. About Your PPO PacificSource has selected the participating physicians, practitioners, and hospitals after carefully reviewing their qualifications. Each health care provider has agreed to a contracted amount in payment for their services. Additionally, you cannot be 'balanced billed' for the difference between the PPO contracted amount and the provider's normal billed charge for a particular service. You are only responsible for the deductible, co-payment, and/or co-insurance payment shown on the Medical Benefit Summary. Enrolling in this plan does not guarantee that a particular participating provider will remain a participating provider or that a particular participating providerwill provide members under this plan only with covered services. Members should verify a health care provider's status as a participating provider each time services are received from the health care provider. It is not safe to assume that when you are treated at a participating medical facility, all services are performed by participating providers. A list of participating providers can be accessed through the PacificSource website: PacificSource.com or by calling PacificSource at (888) 977-9299. Whenever possible, you should arrange for professional services such as surgery and anesthesiology to be provided by a participating provider. Doing so will help you maximize your benefits and limit your out-of- pocket expenses. The PPO benefits are outlined on the Medical Benefit Summary. You have a free choice of any health care provider, and the physician-patient relationship shall be maintained. Members, together with their health care provider, are ultimately responsible for determining the appropriate course of medical treatment, regardless of whether the plan will pay for all or a portion of the cost of such care. The participating providers are merely independent contractors; neither the plan, the Plan Sponsor, nor PacificSource makes any warranty as to the quality of care that may be rendered by any participating provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from this plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of the participating providers and/or a list of participating health care professionals SPD 0714_City of Ashland V2 091614 20 who specialize in obstetrics or gynecology, contact PacificSource at (888) 977-9299 or PO Box 7068, Springfield, OR 97475-0068. Non-PPO Providers When you receive services or supplies from a nonparticipating provider, your out-of-pocket expense is likely to be higher than if you had used a participating provider. Besides the non-PPO deductible, co- payment, and/or co-insurance amounts shown on the Medical Benefit Summary, you may become responsible for the provider's billed amount that exceeds the plan's allowable amount. Example of Provider Payment The following illustrates how payment could be made for a covered service billed at $120. In this example, the Medical Benefit Summary shows a participating providers co-insurance of 20 percent and a non-participating providers co-insurance of 30 percent. This is only an example; your plan's benefits may be different. Participating Non-participating Provider Provider Provider's usual billed charge $120 $120 PPG's negotiated provider discount $20 $0 Plan's allowable amount $100 $100 Percent of payment 20% 30% Plan's payment $80 $70 Patient's amount of allowable amount $20 $30 Charges above the allowable amount $0 $20 Patient's total payment to provider $20 $50 Percent of charge paid by plan 80% 58% Percent of charge paid by patient 20% 42% Allowable Amount The plan bases payment to nonparticipating providers on an allowable amount for the same services or supplies. Several sources are used to determine the allowable amount, depending on the service or supply and the geographical area where it is provided. The allowable amount may be based on data collected from the Centers for Medicare and Medicaid Services (CMS), Viant Health Payment Solutions, other nationally recognized databases, or PacificSource. NETWORK NOT AVAILABLE BENEFITS The term `network not available' is used when a member does not have reasonable geographic access to a participating provider for a covered medical service or supply. If you live in an area without access to a participating provider for a specific service or supply, your plan's Network Not Available benefits apply. Here's how that works: • You seek treatment from a nearby non-participating provider of that service or supply. • PacificSource determines the allowable fee for that service or supply (the term `allowable fee' is explained above under the Non-participating Providers section). • PacificSource applies the Network Not Available benefit level stated in your Medical Benefit Summary to the allowable fee to calculate covered expenses. • You are responsible for any co-payments, co-insurance, deductibles, and amounts over the allowable fee. COVERAGE WHILE TRAVELING Your plan is powered by the PacificSource Network (PSN). The PSN Network covers Oregon, Idaho, Montana, southwest Washington, and eastern Washington. When you need medical services outside of the PSN Network, you can save out-of-pocket expense by using the participating providers available through The First Health@ Network. SPD 0714_City of Ashland V2 091614 21 Nonemergency Care While Traveling To find a participating provider outside the regions covered by the PacificSource Network, call The First Health® Network at (800) 226-5116. (The phone number is also printed on your PacificSource ID card for convenience.) Representatives are available at any time to help you find a participating physician, hospital, or other outpatient provider. Nonemergency care outside of the United States is not covered. • If a participating provider is available in your area, your plan's participating provider benefits will apply if you use a participating provider. • If a participating provider is not available in your area, your plan's Network Not Available benefits will apply. • If a participating provider is available but you choose to use a non-participating provider, your plan's non-participating provider benefits will apply. Emergency Services While Traveling In medical emergencies (see the Covered Expenses - Emergency Services section of this Summary Plan Description), your plan pays benefits at the participating provider level regardless of your location. Your covered expenses are based on PacificSource's allowable fee. If you are admitted to a hospital as an inpatient following the stabilization of your emergency condition, your physician or hospital should contact the PacificSource Health Services Department at (888) 691-8209 as soon as possible to make a benefit determination on your admission. If you are admitted to a non-participating hospital, PacificSource may require you to transfer to a participating facility once your condition is stabilized in order to continue receiving benefits at the participating provider level. FINDING PARTICIPATING PROVIDER INFORMATION You can find up-to-date participating provider information: • By asking your healthcare provider if he or she is a participating provider for your Plan Sponsor's plan. • On the PacificSource website, PacificSource.com. Simply click on 'Find a Provider' and you can easily look up participating providers or print your own customized directory. • By contacting the PacificSource Customer Service Department. PacificSource can answer your questions about specific providers. If you'd like a complete provider directory for your plan, just ask - PacificSource will be glad to mail you a directory free of charge. • By calling The First Health® Network at (800) 226-5116 if you live outside the area covered by the PacificSource Network. TERMINATION OF PROVIDER CONTRACTS PacificSource will notify you within ten days of learning of the termination of a provider contractual relationship if you have received services in the previous three months from such a provider when: • A provider terminates a contractual relationship with PacificSource in accordance with the terms and conditions of the agreement; • A provider terminates a contractual relationship with an organization under contract with PacificSource; or • PacificSource terminates a contractual relationship with an individual provider or the organization with which the provider is contracted in accordance with the terms and conditions of the agreement. For the purposes of continuity of care, PacificSource may require the provider to adhere to the medical services contract and accept the contractual reimbursement rate applicable at the time of contract termination. SPD 0714_City of Ashland V2 091614 22 BECOMING ELIBIGLE Who Pays for Your Benefits The Plan Sponsor shares the cost of providing benefits for you and your enrolled dependents. From time to time, the Plan Sponsor may adjust the amount of contributions required for coverage. In addition, the deductibles and co-payments may also change periodically. You will be notified by your Plan Sponsor of any changes in the cost of plan coverage before they take effect. Who is Eligible Employees - You are eligible to participate in this plan if you are a regular, full-time employee of the Plan Sponsor upon the completion of the minimum number of hours and probationary waiting period set by your Plan Sponsor. Your Plan Sponsor's eligibility requirements are stated in your Medical Benefit Summary. All employees who meet those requirements are eligible for coverage. Eligibility for Medicaid or the receipt of Medicaid benefits will not be taken into account in determining eligibility. Status as an employee is determined under the employment records of the Plan Sponsor. Workers classified by the Plan Sponsor as independent contractors are not eligible for this plan under any circumstances. Retirees - You are eligible to participate in this plan if you are a retired employee of the Plan Sponsor, or a spouse of a retired employee. Eligibility for Medicaid or the receipt of Medicaid benefits will not be taken into account in determining eligibility. Dependents - While you are enrolled under this plan, the following family members, and only the following family members, are also eligible to participate in the plan: • Your legal spouse or qualified domestic partner. The Plan Sponsor may require documentation proving a legal marital relationship, an Affidavit of Domestic Partnership or a Certificate of Qualified domestic partnership. • Your, your spouse's, or your qualified domestic partner's dependent children under age 26 regardless of the child's place of residence, marital status, or financial dependence on you. • Your, your spouse's, or your qualified domestic partner's unmarried dependent children age 26 or over who are mentally or physically disabled. To qualify as dependents, they must have been continuously unable to support themselves since turning age 26 because of a mental or physical disability. PacificSource requires documentation of the disability from the child's physician, and will review the case before determining eligibility for coverage. • Dependent family member. A brother, sister, niece, nephew or grandchild of an eligible dependent enrolled on your plan under age 26 who is unmarried, not in a domestic partnership, registered or otherwise, who is related to you by blood, marriage, or domestic partnership AND for whom you are the court appointed legal custodian or guardian with the expectation that the family member will live in your household for at least a year. • A child placed for adoption with you, your spouse, or qualified domestic partner. Placed for adoption means the assumption and retention by you, your spouse, or qualified domestic partner of a legal obligation for total or partial support of a child in anticipation of adoption or placement for adoption. Upon any termination of such legal obligations the placement for adoption shall be deemed to have terminated. • A foster child placed with you, your spouse, or your qualified domestic partner. Placement means an individual who is placed by an authorized placement agency or by judgment, decree, or other order of any court of competent jurisdiction. Coverage will continue assuming continued eligibility under this plan unless placement is disrupted and the child is removed from placement. 'Dependent children' means any natural, step, foster children or adopted children as well as any child placed for adoption with you or your domestic partner are legally obligated to support or contribute support for. • No family or household members other than those listed above are eligible to enroll under your coverage. Special Rules for Eligibility - At any time, the Plan Administrator may require proof that a person qualifies or continues to qualify as a dependent as defined by this plan. SPD 0714_City of Ashland V2 091614 23 ENROLLING DURING THE INITIAL ENROLLMENT PERIOD The `initial enrollment period' is the 60-day period beginning on the date a person is first eligible for enrollment in this plan. Everyone who becomes eligible for coverage has an initial enrollment period. When you satisfy your Plan Sponsor's probationary waiting period at the hours required for eligibility and become eligible to enroll in this plan, you and your eligible family members must enroll within the initial enrollment period. If you miss your initial enrollment period, you may be subject to a waiting period. (For more information, see `Special Enrollment Periods' and `Late Enrollment' under the Enrolling After the Initial Enrollment Period section.) To enroll, you must complete and sign an enrollment application, which is available from your Plan Sponsor. The application must include complete information on yourself and your enrolling family members. Return the application to your Plan Sponsor, and your Plan Sponsorwill send it to PacificSource. Coverage for you and your enrolling family members begins on the first day of the month after you satisfy your Plan Sponsor's probationary waiting period. The probationary waiting period is stated in your Medical Benefit Summary. Coverage will only begin if Your Plan Sponsor receives your enrollment application and premium. Newborns Your, your spouse's, or your qualified domestic partner's natural born baby is eligible for enrollment under this plan during the 60-day initial enrollment period after birth. PacificSource cannot enroll the child and pay benefits until your Plan Sponsor receives an enrollment application listing the child as your dependent. A claim for maternity care is not considered notification for the purpose of enrolling a newborn child. Anytime there is a delay in providing enrollment information, your Plan Sponsor may ask for legal documentation to confirm validity. Adopted Children When a child is placed in your home for adoption, the child is eligible for enrollment under this plan during the 60-day initial enrollment period after placement for adoption. `Placement for adoption' means the assumption and retention by you, your spouse, or your domestic partner of a legal obligation for full or partial support and care of the child in anticipation of adoption of the child. To add the child to your coverage, you must complete and submit an enrollment application listing the child as your dependent. You may be required to submit a copy of the certificate of adoption or other legal documentation from a court or a child placement agency to complete enrollment. If additional premium is required, then the natural born or adopted child's eligibility for enrollment will end 60 days after placement if Plan Sponsor has not received an enrollment application and premium. Premium is charged from the date of placement and prorated for the first month. If no additional premium is required, then the natural born or adopted child's eligibility continues as long as you are covered. However, PacificSource cannot enroll the child and pay benefits until your Plan Sponsor receives an enrollment application listing the child as your dependent. Foster Children When a foster child is placed in your home, you have 60 days from the date of placement to enroll them in your plan. To enroll the child, your Plan Sponsor must receive your enrollment application and additional premium within 60 days of the placement. Coverage for your new family members will begin on the date of placement. You may be required to submit a copy of the legal documentation from a court or a child placement agency to complete enrollment. Family Members Acquired by Marriage If you marry, you may add your new spouse and any newly eligible dependent children to your coverage during the 60-day initial enrollment period after the marriage. Your Plan Sponsor must receive your enrollment application and additional premium during the initial enrollment period. Coverage for your new family members will then begin on the first day of the month after the marriage. You may be required to submit a copy of your marriage certificate to complete enrollment. SPD 0714_City of Ashland V2 091614 24 Family Members Acquired by Domestic Partnership If you and your same-gender domestic partner have been issued a Certificate of Qualified domestic partnership, your domestic partner and your partner's dependent children are eligible for coverage during the 60-day initial enrollment period after the registration of the domestic partnership. Your Plan Sponsor must receive your enrollment application and additional premium during the initial enrollment period. Coverage for your new family members will then begin on the first day of the month after the registration of the domestic partnership. You may be required to submit a copy of your Certificate of Qualified domestic partnership to complete enrollment. Unregistered same-gender domestic partners and their children may also become eligible for enrollment. If you and your unqualified domestic partner meet the criteria on the Affidavit of Domestic Partnership supplied by your Plan Sponsor, your domestic partner and your partner's dependent children are eligible for coverage during the 60-day initial enrollment period after the requirements of the Affidavit of Domestic Partnership are satisfied. Your Plan Sponsor must receive your enrollment application, a copy of your Affidavit of Domestic Partnership, and additional premium during the initial enrollment period. Coverage for your new family members will then begin on the first day of the month after the Affidavit of Domestic Partnership is satisfied. Family Members Placed in Your Guardianship If a court appoints you custodian or guardian of an eligible dependent child, you may add that family member to your coverage. To be eligible for coverage, the family member must be: • Unmarried; • Not in a domestic partnership, registered or otherwise; • Related to you by blood, marriage, or domestic partnership; • Under age 26-1 and • Expected to live in your household for at least a year. Your Plan Sponsor must receive your enrollment application and additional premium during the 60-day initial enrollment period beginning on the date of the court appointment. Coverage will then begin on the first day of the month following the date of the court order. You may be required to submit a copy of the court order to complete enrollment. Qualified Medical Child Support Orders This health plan complies with qualified medical child support orders (QMCSO) issued by a state court or state child support agency. A QMCSO is a judgment, decree, or order, including approval of a settlement agreement that provides for health benefit coverage for the child of a plan member. If a court or state agency orders coverage for your spouse or child, they may enroll in this plan within the 60-day initial enrollment period beginning on the date of the order. Coverage will become effective on the first day of the month after Plan Sponsor receives the enrollment application. You may be required to submit a copy of the QMCSO to complete enrollment. ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD Returning to Work after a Layoff If you are laid off and then rehired by your Plan Sponsor within six months, you will not have to satisfy another probationary waiting period or new exclusion period. Your health coverage will resume the first of the month following the date you return to work and again meet your Plan Sponsor's minimum hour requirement. If your family members were covered before your layoff, they can resume coverage at that time as well. You must re-enroll your family members by submitting an enrollment application within the 60-day initial enrollment period following your return to work. Returning to Work after a Leave of Absence If you return to work after a Plan Sponsor-approved leave of absence of six months or less, you will not have to satisfy another probationary waiting period. Your health coverage will resume the day you return to work and again meet your Plan Sponsor's minimum hour requirement. If your family members SPD 0714_City of Ashland V2 091614 25 were covered before your leave of absence, they can resume coverage at that time as well. You must re-enroll your family members by submitting an enrollment application within the 60-day initial enrollment period following your return to work. Returning to Work after Family Medical Leave Your Plan Sponsor is probably subject to the Family Medical Leave Act (FMLA). To find out if you have rights under FMLA, ask your health plan administrator. Under FMLA, if you return to work after a qualifying FMLA medical leave, you will not have to satisfy another probationary waiting period or any previously satisfied exclusion period under this plan. Your health coverage will resume the day you return to work and meet your Plan Sponsor's minimum hour requirement. If your family members were covered before your leave, they can also resume coverage at that time if you re-enroll them within the 60-day initial enrollment period following your return. Special Enrollment Periods If you are eligible to decline coverage and you wish to do so, you must submit a written waiver of coverage to your Plan Sponsor. You and your family members may enroll in this plan later if you qualify under Rule #1, Rule #2, or Rule #3 below. • Special Enrollment Rule #1 - If you declined enrollment for yourself or your family members because of other health insurance coverage, you or your family members may enroll in the plan later if the other coverage ends involuntarily. 'Involuntarily' means coverage ended because continuation coverage was exhausted, employment terminated, work hours were reduced below the Plan Sponsor's minimum requirement, the other insurance plan was discontinued or the maximum lifetime benefit of the other plan was exhausted, the Plan Sponsor's premium contributions toward the other insurance plan ended, or because of death of a spouse, divorce, or legal separation. To do so, you must request enrollment within 60 days after the other health insurance coverage ends (or within 60 days after the other health insurance coverage ends if the other coverage is through Medicaid or a State Children's Health Insurance Program). Coverage will begin on the first day of the month after the other coverage ends. • Special Enrollment Rule #2 - If you acquire new dependents because of marriage, qualification of domestic partnership, birth, or placement for adoption, you may be able to enroll yourself and/or your newly acquired eligible dependents at that time. To do so, you must request enrollment within 60 days after the marriage, registration of the domestic partnership, birth, placement of foster child, or placement for adoption. In the case of marriage or domestic partnership, coverage begins on the first day of the month after the marriage or registration of the domestic partnership. In the case of birth or placement for adoption, coverage begins on the date of birth or placement. • Special Enrollment Rule #3 - If you or your dependents become eligible for a premium assistance subsidy under Medicare or CHIP, you may be able to enroll yourself and/or your dependents at that time. To do so, you must request enrollment within 60 days of the date you and/or your dependents become eligible for such assistance. Coverage will begin on the first day of the month after becoming eligible for such assistance. Dental Enrollment Employees or their dependents who did not enroll with dental benefits when initially eligible may later enroll on the policy's anniversary date. Employees and/or dependents who enrolled with dental benefits under this policy but later terminated coverage may enroll on an anniversary date of the policy following a 24-month waiting period from the date coverage was last terminated. Late Enrollment If you did not enroll during your initial enrollment period and you do not qualify for a special enrollment period, your enrollment will be delayed until the plan's anniversary date. Alate enrollee' is an otherwise eligible employee or dependent who does not qualify for a special enrollment period explained above, and who: • Did not enroll during the 60-day initial enrollment period; or • Enrolled during the initial enrollment period but discontinued coverage later. SPD 0714_City of Ashland V2 091614 26 A late enrollee may enroll by submitting an enrollment application to your Plan Sponsor during an open enrollment period designated by your Plan Sponsorjust prior to the plan's anniversary date. When you or your dependents enroll during the open enrollment period, plan coverage begins on the date Plan Sponsor receives the enrollment application or on the plan's anniversary date. You may enroll in coverage prior to an open enrollment period if one of the following exceptions are met: • You and/or your dependent may enroll in coverage if you involuntary lose other Group Coverage or lose coverage under the Oregon Health Plan. • You and/or your dependent may enroll in coverage if your hours per week are increased or your employer's contribution is increased. You and/or your dependent may also enroll if you return from a qualified FMLA leave. Member ID Card The membership card issued to you by PacificSource is for identification purposes only. Possession of a membership card confers no right to services or benefits under this plan and misuse of your membership card may be grounds for termination of your coverage under this plan. To be eligible for services or benefits under this plan, you must be eligible and enrolled in the plan and you must present the membership card to your health care provider. If you receive services or benefits for which you are not entitled to receive under the terms of this plan, you may be charged for such services or benefits at the prevailing rate. If you permit the use of your membership card by any other person, your card may be retained by this plan, and all your rights under this plan may be terminated. PLAN SELECTION PERIOD If your Plan Sponsor offers more than one benefit plan option, you may choose another plan option only upon your plan's anniversary date. You may select a different plan option by completing a selection form or application form. Coverage under the new plan option becomes effective on your plan's anniversary date. TERMINATING COVERAGE If you leave your job for any reason or your work hours are reduced below your Plan Sponsor's minimum requirement, coverage for you and your enrolled family members will end. Coverage ends on the last day of the last month in which you worked full time. You may, however, be eligible to continue coverage for a limited time; please see the Continuation section of this Summary Plan Description for more information. You can voluntarily discontinue coverage for your enrolled family members at any time by completing a Termination of Dependent Coverage form and submitting it to your Plan Sponsor. Keep in mind that once coverage is discontinued, your family members may be subject to the late enrollment waiting period if they wish to re-enroll later. Divorced Spouses If you divorce, coverage for your spouse will end on the last day of the month in which the divorce decree or legal separation is final. You must notify your Plan Sponsor of the divorce or separation, and continuation coverage may be available for your spouse. If there are special child custody circumstances, please contact your Plan Sponsor. Please see the Continuation section for more information. Dependent Children When your enrolled child no longer qualifies as a dependent, coverage will end on the last day of that month. Please see the Eligibility section of this Summary Plan Description for information on when your dependent child is eligible beyond age 25. The Continuation section includes information on other coverage options for those who no longer qualify for coverage. Dissolution of Domestic Partnership If you dissolve your domestic partnership, coverage for your domestic partner and their children not related to you by birth or adoption will end on the last day of the month in which the dissolution of the SPD 0714_City of Ashland V2 091614 27 domestic partnership is final. You must notify your Plan Sponsor of the dissolution of the domestic partnership.. Domestic partners and their covered children are not recognized as qualified beneficiaries under federal COBRA continuation laws. Domestic partners and their covered children may not continue this policy's coverage under COBRA independent of the employee (see COBRA Continuation in the Continuation of Coverage section). Certificates of Creditable Coverage A certificate of creditable coverage is used to verify the dates of your prior health plan coverage when you apply for coverage under a new policy. These certificates are issued by health insurers whenever a plan participant's coverage ends. After your or your dependent's coverage under this plan ends, you will receive a certificate of creditable coverage by mail. PacificSource has an automated process that generates and mails these certificates whenever coverage ends. PacificSource will send a separate certificate for any dependents with an effective or termination date that differs from yours. For questions or requests regarding certificates of creditable coverage, you are welcome to contact Membership Services Department at (541) 684-5583 or (866) 999-5583. CONTINUATION OF COVERAGE Under federal and state laws, you and your family members may have the right to continue this plan's coverage for a specified time. You and your dependents may be eligible if: • Your employment ends or you have a reduction in hours • You take a leave of absence for military service • You divorce • You die • You become eligible for Medicare benefits if it causes a loss of coverage for your dependents • Your children no longer qualify as dependents The following sections describe your rights to continuation under state and federal laws, and the requirements you must meet to enroll in continuation coverage. USERRA CONTINUATION If you take a leave of absence from your job due to military service, you have continuation rights under the Uniformed Services Employment and Re-employment Rights Act (USERRA). You and your enrolled family members may continue this plan's coverage if you, the employee, no longer qualify for coverage under the plan because of military service. Continuation coverage under USERRA is available for up to 24 months while you are on military leave. If your military service ends and you do not return to work, your eligibility for USERRA continuation coverage will end. Premium for continuation coverage is your responsibility. The following requirements apply to USERRA continuation: • Family members who were not enrolled in the group plan cannot take continuation. The only exceptions are newborn babies and newly acquired dependents not covered by another group health plan. • To apply for continuation, you must submit a completed Continuation Election Form to your Plan Sponsor within 60 days after the last day of coverage under the group plan. • You must pay continuation premium to your Plan Sponsor by the first of each month. Your Plan Sponsorwill include your continuation premium in the group's regular monthly payment. PacificSource cannot accept the premium directly from you. • Your Plan Sponsor must still be self-insured through PacificSource. If your Plan Sponsor discontinues this plan, you will no longer qualify for continuation. Surviving or Divorced Spouses and Qualified Domestic Partners If you die, divorce, or dissolve your qualified domestic partnership, and your spouse or qualified domestic partner is 55 years or older, your spouse or qualified domestic partner may be able to SPD 0714_City of Ashland V2 091614 28 continue coverage until eligible for Medicare or other coverage. Dependent children are subject to the health plan's age and other eligibility requirements. Some restrictions and guidelines apply; please see your Plan Sponsorfor specific details. COBRA CONTINUATION Your Plan Sponsor is subject to the continuation of coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) as amended. To find out if you have continuation rights under COBRA, ask your health plan administrator. COBRA Eligibility To be eligible, a member must experience a 'qualifying event' which is an event that causes your regular group coverage to end and makes you eligible for continuation coverage. When the following qualifying events happen, you may continue coverage for the lengths of time shown: Qualifying Event Continuation Period Employee's termination of employment or reduction in Employee, spouse, and children may continue for up to hours 18 months' Employee's divorce or legal separation Souse and children may continue for u to 36 months Employee's eligibility for Medicare benefits if it causes a Spouse and children may continue for up to 36 months loss of coverage Employee's death Souse and children may continue for u to 36 months Child no longer qualifies as a dependent Child may continue for u to 36 months Em to er files for Cha ter 11 bankru tc Onl a lies to retirees and their covered dependents If the employee or covered dependent is determined disabled by the Social Security Administration within the first 60 days of continuation coverage, all qualified beneficiaries may continue coverage for up to an additional 11 months, for a total of up to 29 months. 2 The total maximum continuation period is 36 months, even if there is a second qualifying event. A second qualifying event might be a divorce, legal separation, death, or child no longer qualifying as a dependent after the employee's termination or reduction in hours. If your dependents were not covered prior to your qualifying event, they may enroll in the continuation coverage while you are on continuation. They will be subject to the same rules that apply to active employees, including the late enrollment waiting period. If your employment is terminated for gross misconduct, you and your dependents are not eligible for COBRA continuation. Domestic partners and their covered children may not continue this policy's coverage under COBRA independent of the employee. When Continuation Coverage Ends Your continuation coverage will end before the end of the continuation period above if any of the following occur: • Your continuation premium is not paid on time. • You become covered under another group health plan that does not exclude or limit treatment for your pre-existing conditions. • You become entitled to Medicare benefits. • Your Plan Sponsor discontinues its health plan and no longer offers a group health plan to any of its employees. • Your continuation period was extended from 18 to 29 months due to disability, and you are no longer considered disabled. Type of Coverage Under COBRA, you may continue any coverage you had before the qualifying event. If your Plan Sponsor provides both medical and dental coverage and you were enrolled in both, you may continue both medical and dental. If your Plan Sponsor provides only one type of coverage, or if you were enrolled in only one type of coverage, you may continue only that coverage. SPD 0714_City of Ashland V2 091614 29 COBRA continuation benefits are always the same as your Plan Sponsor's current benefits. Your Plan Sponsor has the right to change the benefits of its health plan or eliminate the plan entirely. If that happens, any changes to the group health plan will also apply to everyone enrolled in continuation coverage. Your Responsibilities and Deadlines You must notify your Plan Sponsor within 60 days if you divorce, or if your child no longer qualifies as a dependent. That will allow your Plan Sponsor to notify you or your dependents of your continuation rights. When your Plan Sponsor learns of your eligibility for continuation, your Plan Sponsor will notify you of your continuation rights and provide a Continuation Election Form. You then have 60 days from that date or 60 days from the date coverage would otherwise end, whichever is later, to enroll in continuation coverage by submitting a completed Election Form to your Plan Sponsor. If continuation coverage is not elected during that 60-day period, coverage will end on the last day of the last month you were an active employee. If you do not provide these notifications within the time frames required by COBRA, Plan Sponsor's responsibility to provide coverage under the health plan will end. Continuation Premium You or your family members are responsible for the full cost of continuation coverage. The monthly premium must be paid to your Plan Sponsor. PacificSource cannot accept continuation premium directly from you. You may make your first premium payment any time within 45 days after you return your Continuation Election Form to your Plan Sponsor. After the first premium payment, each monthly payment must reach your Plan Sponsorwithin 30 days of your Plan Sponsor's premium due date. If your Plan Sponsor does not receive your continuation premium on time, continuation coverage will end. If your coverage is canceled due to a missed payment, it will not be reinstated for any reason. Premium rates are established annually and may be adjusted if the plan's benefits or costs change. Keep Your Plan Informed of Address Changes In order to protect your and your family's rights, you should keep the Plan Sponsor informed of any changes in your address and the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Sponsor. CONTINUATION WHEN YOU RETIRE If you retire, you and your insured dependents are eligible to continue coverage subject to the following: • You must apply for continued coverage within 60 days after retirement. • You must be receiving benefits from PERS (Public Employee Retirement System) or from a similar retirement plan offered by your Plan Sponsor. • You will have the same opportunity to switch to another plan during the open enrollment period as do active employees. If the plan's benefits are changed by the policyholder, your benefits will change accordingly. • Except for newly acquired dependents due to marriage, registration of domestic partnership, birth, or adoption, only your dependents who were covered at the time of retirement may continue coverage under this provision. You may add a new spouse, domestic partner, or other newly acquired dependent after retirement if family coverage is available. A completed enrollment application must be submitted within 60 days of the date of marriage, registration of domestic partnership, birth, or adoption. Your continuation coverage will end when any one of the following occurs: • When full premium is not paid or when your coverage is voluntarily terminated, your coverage will end on the last day of the month for which premium was paid. • When you become eligible for Medicare coverage, your coverage will end on the last day of the month preceding Medicare eligibility. • When the regular group policy is terminated, your coverage will end on the date of termination. SPD 0714_City of Ashland V2 091614 30 Your dependent's continuation coverage will end when any one of the following occurs: • When full premium for the dependent is not paid or when the dependent's coverage is voluntarily terminated by you or your dependent, coverage will end on the last day of the month for which premium was paid. • When your dependent becomes eligible for Medicare coverage, your dependent's coverage will end on the last day of the month preceding Medicare eligibility. • When you die, divorce, or dissolve your domestic partnership, your dependent's coverage will end on the last day of the month following the death, divorce, or dissolution of the domestic partnership. • When your dependent is otherwise no longer considered a dependent under the group plan, his or her coverage will end on the last day of the month of their eligibility. Continuation of coverage may be available under COBRA continuation (see Continuation of Coverage provisions). • When the regular group policy is terminated, your dependent's coverage will end on the date of termination. WORK STOPPAGE Labor Unions If you are a union member, you have certain continuation rights in the event of a labor strike. Your union is responsible for collecting your premium and can answer questions about coverage during the strike. EXTENSION OF BENEFITS If you are on a Plan Sponsor-approved non-FMLA leave of absence, you may continue coverage under active status for up to three months by self-pay to the Plan Sponsor. Absences extending beyond three months will be subject to the Continuation of Coverage provisions of this plan. COVERED EXPENSES This plan provides comprehensive medical coverage when care is medically necessary to treat an illness or injury. Be careful - just because a treatment is prescribed by a healthcare professional does not mean it is medically necessary under the terms of the plan. Also remember that just because a service or supply is a covered benefit under this plan does not necessarily mean all billed charges will be paid. Some medically necessary services and supplies may be excluded from coverage under this plan. Be sure you read and understand the Benefit Limitations and Exclusions section of this book, including the section on Preauthorization. If you ever have a question about your plan benefits, contact the PacificSource Customer Service Department. Medical Necessity Except for specified Preventive Care services, the benefits of this health plan are paid only toward the covered expense of medically necessary diagnosis or treatment of illness or injury. This is true even though the service or supply is not specifically excluded. All treatment is subject to review for medical necessity. Review of treatment may involve prior approval, concurrent review of the continuation of treatment, post-treatment review or any combination of these. For additional information, see 'medically necessary' in the Definitions section of this Summary Plan Description. Be careful. Your healthcare provider could prescribe services or supplies that are not covered under this plan. Also, just because a service or supply is a covered benefit does not mean all related charges will be paid. Healthcare Providers This plan provides benefits only for covered expenses and supplies rendered a physician (M.D. or O.D.), practitioner, nurse, hospital or specialized treatment facility, durable medical equipment supplier, or other licensed medical provider as specifically stated in this Summary Plan Description. The services or supplies provided by individuals or companies that are not specified as eligible practitioners are not SPD 0714_City of Ashland V2 091614 31 eligible for reimbursement under the benefits of this plan. For additional information, see 'practitioner', `specialized treatment facility', and 'durable medical equipment supplier' in the Definitions section of this Summary Plan Description. Your Annual Deductible Deductible Carryover. The deductible must be satisfied only once in any benefit year, even though there may be several conditions treated. Covered expenses incurred during the last three (3) months of the previous benefit year will be applied to the subsequent year's benefit year deductible subject to the following: • The covered expenses were applied to the deductible; • The covered expenses were incurred during the last three (3) months of the year; and • The prior year's deductible was not satisfied. Final determination of which expenses apply to the deductible will be based on the order in which charges are incurred, even if bills for charges are not received in that order. Your Annual Out-of-Pocket Limit This plan has an out-of-pocket limit provision to protect you from excessive medical expenses. The Medical Benefit Summary shows your plan's annual out-of-pocket limits for participating and/or nonparticipating providers. If you incur covered expenses over those amounts, this plan will pay 100 percent of eligible charges, subject to the allowable fee. Your expenses for the following do not count toward the annual out-of-pocket limit: • Charges applied to deductible, if applicable to your plan • Co-payments, if applicable to your plan • Prescription drugs • Charges over the allowable fee for services of non-participating providers • Incurred charges that exceed amounts allowed under this plan Charges over the allowable fee for services of non-participating providers, and incurred charges that exceed amounts allowed under this plan, and co-payments will continue to be your responsibility even after the out-of-pocket or stop-loss limit is reached. Prescription drug benefits are not affected by the out-of-pocket or stop-loss limit. You will still be responsible for that co-payment or co-insurance payment even after the out-of-pocket or stop-loss limit is reached. MEDICAL BENEFITS About Your Medical Benefits All benefits provided under this plan must satisfy some basic conditions. The following conditions are commonly included in health benefit plans but are often overlooked or misunderstood. Medical Necessity - The plan provides benefits only for covered services and supplies that are medically necessary for the treatment of a covered illness or injury. Be careful-just because a treatment is prescribed by a healthcare professional does not necessarily mean it is medically necessary as defined by the plan. And, some medically necessary services and supplies may be excluded from coverage. Also, the treatment must not be experimental and/or investigational. Allowable Fees - The plan provides benefits only for covered expenses that are equal to or less than the allowable amount, as defined by the plan, in the geographic area where services or supplies are provided. Any amounts that exceed the allowable amount are not recognized by the plan for any purpose. Health Care Provider - The plan provides benefits only for covered expenses and supplies rendered by a physician, practitioner, nurse, hospital or specialized treatment facility, durable medical equipment supplier, or other licensed medical provider as specifically stated in this plan summary. The services or supplies provided by individuals or companies that are not specified as eligible practitioners are not SPD 0714_City of Ashland V2 091614 32 eligible for reimbursement under the benefits of this plan. For additional information, see practitioner, specialized treatment facility, and durable medical equipment in the Definitions section of this document. Custodial Care Providers - The plan does not provide benefits for services and supplies that are furnished primarily to assist an individual in the activities of daily living. Activities of daily living include such things as bathing, feeding, administration of oral medications,'academic, social, or behavior skills training, and other services that can be provided by persons without the training of a health care practitioner. Benefit Year - The word year, as used in this document, refers to the benefit year, which is the 12- month period beginning January 1 and ending December 31. Unless otherwise specified, all annual benefit maximums and deductibles accumulate during the benefit year. Deductibles - A deductible is the amount of covered expenses you must pay during each year before the plan will consider expenses for reimbursement. The individual deductible applies separately to each covered person. The family deductible applies collectively to all covered persons in the same family. When the family deductible is satisfied, no further deductible will be applied for any covered family member during the remainder of the year. The annual individual and family deductible amounts are shown on the Medical Benefit Summary. Benefit Percentage Payable - Benefit percentage payable represents the portion of covered expenses paid by the plan after you have satisfied any applicable deductible. These percentages apply only to covered expenses which do not exceed the allowable amount. You are responsible for all remaining covered and non-covered expenses, including any amount that exceeds the allowable amount for covered services. The benefit percentages payable are shown on the Medical Benefit Summary. Co-payments - Co-payments are the first-dollar amounts you must pay for certain covered services, which are usually paid at the time the service is performed (i.e. physician office visits or emergency room visits). These co-payments do not apply to your annual deductible or out-of-pocket maximum, unless otherwise specified on the Medical Benefit Summary. The co-payment amounts are shown on the Medical Benefit Summary. Out-Of-Pocket Maximum(s) -An out-of-pocket maximum is the maximum amount of covered expenses you must pay during a year, before the plan's benefit percentage payable increases. The individual out-of-pocket maximum applies separately to each covered person. When a covered person reaches the annual out-of-pocket maximum, the plan will pay 100% of additional covered expenses for that individual during the remainder of that year, subject to the lifetime maximum amount, if applicable. However, expenses for services which do not apply to the out-of-pocket maximum will never be paid at 100%. The annual individual and family out-of-pocket maximum amounts are shown on the Medical Benefit Summary. Benefit Maximums - Total plan payments for each covered person are limited to certain maximum benefit amounts. A benefit maximum can apply to specific benefit categories or to all benefits. A benefit maximum amount may also apply to a specific time period, such as annual. Least Costly Setting For Services - Benefits of the plan provide for reimbursement of covered services performed in the least costly setting where services can be safely provided. If a procedure can be done safely in an outpatient setting but is performed in a hospital inpatient setting, this plan will only pay what it would have paid for the procedure on an outpatient basis. If services are performed in an inappropriate setting, your benefits may be reduced. PLAN BENEFITS This plan provides benefits for the following services and supplies as outlined on your Medical Benefit Summary. These services and supplies may require you to satisfy a deductible, make a co-payment, or both, and they may be subject to additional limitations or maximum dollar amounts. For a medical expense to be eligible for payment, you must be covered under this plan on the date the expense is incurred. Please refer to your Medical Benefit Summary and the Benefit Limitations and Exclusions section of this Summary Plan Description for more information. SPD 0714_City of Ashland V2 091614 33 Accident Benefit In the event of an injury caused by an accident the plan benefit will be as follows: The first $1,000 of covered expenses within 90 days of an accident is covered at no charge and is not subject to the deductible. The balance is covered as stated in your Medical Benefit Summary for covered expense. 'Accident' means an unforeseen or unexpected event causing injury which requires medical attention. 'Injury' means bodily trauma or damages which is independent of disease or infirmity. The damage must be caused solely through external and accidental means. For the purpose of this benefit, injury does not include musculoskeletal sprains or strains obtained in the performance of physical activity. PREVENTIVE CARE SERVICES This plan covers the following preventive care services when provided by a physician, physician assistant, or nurse practitioner: • Routine physicals for members age 22 and older according to the following schedule: - Ages 22 and over One exam every benefit year Only laboratory work tests and other diagnostic testing procedures related to the routine physical exam are covered by this benefit. Any laboratory tests and other diagnostic testing procedures ordered during, but not related to, a routine physical examination are not covered by this preventative care benefit. Please see Outpatient Services in this section. • Well woman visits, including the following: - One routine gynecological exam each benefit year for women 18 and over. Exams may include Pap smear, pelvic exam, breast exam, blood pressure check, and weight check. Exams may also include an annual mammogram for women over the age of 40, once between the ages of 35-40 unless medically necessary, for the purpose of early detection. Covered lab services are limited to occult blood, urinalysis, and complete blood count. - Routine preventive mammograms for women as recommended. o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for 'Preventive Care - Well Woman Visits' applies to mammograms that are considered 'routine' according to the guidelines of the U.S. Preventive Services Task Force. o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for 'Outpatient Services - Diagnostic and Therapeutic Radiology and Lab' applies to diagnostic mammograms related to the ongoing evaluation or treatment of a medical condition. Pelvic exams and Pap smear exams at any time upon referral of a women's healthcare provider; and pelvic exams and Pap smear exams annually for women 18 to 64 years of age with or without a referral from a women's healthcare provider. - Breast exams annually for women 18 years of age or older or at any time when recommended by a women's healthcare provider for the purpose of checking for lumps and other changes for early detection and prevention of breast cancer. • Colorectal cancer screening exams and lab work including the following: - A fecal occult blood test once per benefit year - A flexible sigmoidoscopy every five benefit years - A colonoscopy for age 50+ every ten benefit years o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for 'Preventive Care - Routine Colonoscopy' applies to colonoscopies that are considered 'routine' according to the guidelines of the U.S. Preventive Services Task Force. o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for 'Professional Services - Surgery' and for 'Outpatient Services - Outpatient Surgery/Services' apply to colonoscopies related to ongoing evaluation or treatment of a medical condition. SPD 0714_City of Ashland V2 091614 34 A double contrast barium enema every five benefit years A colonoscopy performed for screening purposes on individuals at 'high risk' under age 50 is also considered a preventive service. An individual is at high risk for colorectal cancer if the individual has: o Family medical history of colorectal cancer; o Prior occurrence of cancer or precursor neoplastic polyps; o Prior occurrence of a chronic digestive disease condition such as inflammatory bowel disease, o Crohn's disease or ulcerative colitis; or o Other predisposing factors. • Prostate cancer screening, every two benefit years. Exams may include a digital rectal examination and a prostate-specific antigen test. Screenings apply to outpatient surgery/services benefit regardless of whether they are preventive or diagnostic. • Well baby/well child care exams for members age 21 and younger according to the following schedule: - At birth: One standard in-hospital exam - Ages 0 - 2: 12 additional exams during first 36 months of life - Ages 3 - 21: One exam per benefit year Newborn circumcision is a covered benefit even if performed several days after birth. Only laboratory tests and other diagnostic testing procedures related to a well baby/child care exam are covered by this plan. Any laboratory tests and other diagnostic testing procedures ordered during, but not related to, a well baby/child care exam are not covered by this preventative care benefit. Please see Outpatient Services in this section. • Standard age-appropriated childhood and adult immunizations for primary prevention of infectious diseases as recommended by and adopted the Centers for Disease Control and Prevention, American Academy of Pediatrics, American Academy of Family Physicians, or similar standard- setting body. Benefits do not include immunizations for more elective, investigative, unproven, or discretionary reasons (e.g. travel). Covered immunizations include, but may not be limited to the following: - Diphtheria, pertussis, and tetanus (DPT) vaccines, given separately or together - Hemophilus influenza B vaccine Hepatitis A vaccine - Hepatitis B vaccine Human papillomavirus (HPV) vaccine Influenza vaccine Measles, mumps, and rubella (MMR) vaccines, given separately or together Meningococcal (meningitis) vaccine Pneumococcal vaccine Polio vaccine Varicella (chicken pox) vaccine • Tobacco use cessation program services are covered only when provided by a PacificSource approved program. Approved programs are covered at 100% of the cost up to a maximum lifetime benefit of two quit attempts. Approved programs are limited to members age 15 or older. Specific nicotine replacement therapy will only be covered according to the program's description. If this policy includes benefits for prescription drugs, tobacco use cessation related medication prescribed in conjunction with an approved tobacco use cessation program will be covered to the same extent this policy covers other prescription medications. SPD 0714_City of Ashland V2 091614 35 PROFESSIONAL SERVICES This plan covers the following professional services when medically necessary: • Services of a physician (M.D. or D.O.) for diagnosis or treatment of illness or injury • Services of a licensed physician assistant under the supervision of a physician • Services of a certified surgical assistant, surgical technician, or registered nurse (R.N.) when providing medically necessary services as a surgical first assistant during a covered surgery • Services of a nurse practitioner, including certified registered nurse anesthetist (C.R.N.A.) and certified nurse midwife (C.N.M.), for medically necessary diagnosis or treatment of illness or injury • Urgent care services provided by a physician. Urgent care is unscheduled medical care for an illness, injury, or disease that a prudent lay person would consider not life-threatening and treatable at urgent care. Examples of urgent care situations include sprains, cuts, and illnesses that do not require immediate medical attention in order to prevent seriously damaging the health of the person. • Outpatient rehabilitative services provided by a licensed physical therapist, occupational therapist, speech language pathologist, physician, or other practitioner licensed to provide physical, occupational, or speech therapy. Services must be prescribed in writing by a licensed physician, dentist, podiatrist, nurse practitioner, or physician assistant. The prescription must include site, modality, duration, and frequency of treatment. Total covered expenses for outpatient rehabilitative services is limited to a combined maximum of 30 visits per benefit year subject to preauthorization and concurrent review by PacificSource for medical necessity. Only treatment of neurologic conditions (e.g. stroke, spinal cord injury, head injury, pediatric neurodevelopmental problems, and other problems associated with pervasive developmental disorders for which rehabilitative services would be appropriate for children under 18 years of age) may be considered for additional benefits, not to exceed 30 visits per condition, when criteria for supplemental services are met. • Services for speech therapy will only be allowed when needed to correct stuttering, hearing loss, peripheral speech mechanism problems, and deficits due to neurological disease or injury. Speech and/or cognitive therapy for acute illnesses and injuries are covered up to one year post injury when the services do not duplicate those provided by other eligible providers, including occupational therapists or neuropsychologists. • Outpatient pulmonary rehabilitation programs are covered when prescribed by a physician for patients with severe chronic lung disease that interferes with normal daily activities despite optimal medication management. • For related provisions, see 'motion analysis', 'vocational rehabilitation', and 'speech therapy' under 'Excluded Services - Types of Treatments' in the Benefit Limitations and Exclusions section of this Summary Plan Description. • Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to the same payment amounts, conditions, and limitations that apply to similar expenses for illness, except that pregnancy is not considered a pre-existing condition. Please contact the PacificSource Customer Service Department as soon as you learn of your pregnancy. PacificSource's staff will explain your plan's maternity benefits and help you enroll in PacificSource's free prenatal care program. • Routine nursery care of a newborn while the mother is hospitalized and eligible for pregnancy- related benefits under this plan if the newborn is also eligible and enrolled in this plan. • Services of a licensed audiologist for medically necessary audiological (hearing) tests. • Services of a dentist or physician to treat injury of the jaw or natural teeth. Services must be provided within 18 months of the injury. Except for the initial examination, services for treatment of an injury to the jaw or natural teeth require preauthorization to be covered. • Services of a dentist or physician for orthognathic (jaw) surgery as follows: - When medically necessary to repair an accidental injury. Services must be provided within one year after the accident. - For removal of a malignancy, including reconstruction of the jaw within one year after that surgery SPD 0714_City of Ashland V2 091614 36 • Services of a board-certified or board-eligible genetic counselor when referred by a physician or nurse practitioner for evaluation of genetic disease • Medically necessary telemedical health services for health services covered by this plan when provided in person by a healthcare professional when the telemedical health service does not duplicate or supplant a health service that is available to the patient in person. The location of the patient receiving telemedical health services may include, but is not limited to: hospital; rural health clinic; federally qualified health center; physician's office; community mental health center; skilled nursing facility; renal dialysis center; or site where public health services are provided. Coverage of telemedical health services are subject to the same deductible, co-payment, or co-insurance requirements that apply to comparable health services provided in person. HOSPITAL AND SKILLED NURSING FACILITY SERVICES This plan covers medically necessary hospital inpatient services. Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation. Coverage includes eligible services provided by a hospital owned or operated by the state of Oregon, or any state approved mental health and developmental disabilities program. In addition to the hospital room, covered inpatient hospital services may include (but are not limited to): • Cardiac care unit • Operating room • Anesthesia and post-anesthesia recovery • Respiratory care • Inpatient medications • Lab and radiology services • Dressings, equipment, and other necessary supplies The plan does not cover charges for rental of telephones, radios, or televisions, or for guest meals or other personal items. Services of a skilled nursing facility and convalescent homes are covered for up to 120 days per benefit year when preauthorized by PacificSource. Services must be medically necessary. Confinement for custodial care is not covered. Inpatient rehabilitative services are covered up to a maximum of 50 days of rehabilitative care per benefit year, except that treatment for head or spinal cord injuries is covered for up to 60 days per benefit year. Recreation therapy is only covered as part of an inpatient rehabilitation admission. Services must be preauthorized by PacificSource OUTPATIENT SERVICES This plan covers the following outpatient care services: • Advanced diagnostic imaging procedures that are medically necessary for the diagnosis of illness or injury. For purposes of this benefit, advanced diagnostic imaging procedures include CT scans, MRIs, PET scans, CATH labs and nuclear cardiology studies. When services are provided as part of a covered emergency room visit, your plan's emergency room benefit applies. In all other situations and settings, benefits are subject to the deductibles, co-payments, and/or co-insurance stated in your Medical Benefit Summary for Outpatient Services - Advanced Diagnostic Imaging. • Diagnostic radiology and laboratory procedures provided or ordered by a physician, nurse practitioner, or physician assistant. These services may be performed or provided by laboratories, radiology facilities, hospitals, and physicians, including services in conjunction with office visits. • Benefits for members who are receiving services for end-stage renal disease (ESRD), who are eligible for Medicare, are limited to 125% of the current Medicare allowable amount for participating and nonparticipating ESRD service providers. Benefits will continue to be paid at the cost share level applied to other benefits in the same category for members who are not eligible for Medicare. SPD 0714_City of Ashland V2 091614 37 PacificSource will contact members when the first ESRD preauthorization request is received to assist the member in understanding their out-of-pocket expenses and care plan. • Emergency room services. The emergency room co-payment stated in your Medical Benefit Summary covers medical screening and any diagnostic tests needed for emergency care, such as radiology, laboratory work, CT scans, and MRIs. The co-payment does not cover further treatment provided on referral from the emergency room. In true medical emergencies, non-participating providers are paid at the participating provider level. Emergency room charges for services, supplies, or conditions excluded from coverage under this plan are not eligible for payment. Please see the Benefit Limitations and Exclusions section of this Summary Plan Description. • Surgery and other outpatient services. Benefits are based on the setting where services are performed. - For surgeries or outpatient services performed in a physician's office, the benefit stated in your Medical Benefit Summary for Professional Services - Office Procedures and Supplies applies. - For surgeries or outpatient services performed in an ambulatory surgical center or outpatient hospital setting, both the benefits stated in your Medical Benefit Summary for Professional Services - Surgery and the Outpatient Services -Outpatient Surgery/Services apply. • Therapeutic radiology services, chemotherapy, and renal dialysis provided or ordered by a physician. Covered services include a prescribed, orally administered anticancer medication used to kill or slow the growth of cancerous cells. • Other medically necessary diagnostic services provided in a hospital or outpatient setting, including testing or observation to diagnose the extent of a medical condition. EMERGENCY SERVICES In a true medical emergency, this plan covers services and supplies necessary to determine the nature and extent of the emergency condition and to stabilize the patient. An emergency medical condition is an injury or sudden illness, including severe pain, so severe that a prudent layperson with an average knowledge of health and medicine would expect that failure to receive immediate medical attention would risk seriously damaging the health of a person or fetus in the case of a pregnant woman. Examples of emergency medical conditions include (but are not limited to): • Unusual or heavy bleeding • Sudden abdominal or chest pains • Suspected heart attacks • Major traumatic injuries • Serious burns • Poisoning • Unconsciousness • Convulsions or seizures • Difficulty breathing • Sudden fevers If you need immediate assistance for a medical emergency, call 911. If you have an emergency medical condition, you should go directly to the nearest emergency room or appropriate facility. Care for a medical emergency is covered at the participating provider percentage stated in your Medical Benefit Summary even if you are treated at a non-participating hospital. If you are admitted to a non-participating hospital after your emergency condition is stabilized, your Plan Sponsor may require you to transfer to a participating facility in order to continue receiving benefits at the participating provider level. SPD 0714_City of Ashland V2 091614 38 Maternity Services Maternity means, in any one pregnancy, all prenatal services including complications and miscarriage, delivery, postnatal services provided within six months of delivery, and routine nursery care of a newborn child. Maternity services are covered subject to the deductible, co-payments, and/or co- insurance stated in your Medical Benefit Summary regardless of marital status. • Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to the same payment amounts, conditions, and limitations that apply to similar expenses for illness. • Please contact the PacificSource Customer Service Department as soon as you learn of your pregnancy. PacificSource's staff will explain your plan's maternity benefits and help you enroll in PacificSource's free prenatal care program. • This plan provides routine nursery care of a newborn while the mother is hospitalized and eligible for pregnancy-related benefits under this plan if the newborn is also eligible and enrolled in this plan, regardless of marital status. Special Information about Childbirth - This plan covers hospital inpatient services for childbirth according to the Newborns' and Mothers' Health Protection Act of 1996. This plan does not restrict the length of stay for the mother or newborn child to less than 48 hours after vaginal delivery, or to less than 96 hours after Cesarean section delivery. Your provider is allowed to discharge you or your newborn sooner than that, but only if you both agree. For childbirth, your provider does not need to preauthorize your hospital stay with PacificSource. MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES This plan covers medically necessary crisis intervention, diagnosis, and treatment of mental health conditions and chemical dependency. Refer to the Benefit Limitations and Exclusions section of this Summary Plan Description for more information on services not covered by your plan. Mental Health and Chemical Dependency Services It is the intent of this plan to comply with all existing regulations of Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). If for some reason the information presented in the plan differs from the actual regulations of the MHPAEA, the plan reserves the right to administer the plan in accordance with such actual regulations. Providers Eligible for Reimbursement A mental and/or chemical healthcare provider (see Definitions section of this Summary Plan Description) is eligible for reimbursement if: • The mental and/or chemical healthcare provider is approved by the Oregon Department of Human Services; • The mental and/or chemical healthcare provider is accredited for the particular level of care for which reimbursement is being requested by the Oregon Joint Commission on Accreditation of Hospitals or the Commission on Accreditation of Rehabilitation Facilities; or • The patient is staying overnight at the mental and/or chemical healthcare facility (see Definitions section of this Summary Plan Description) and is involved in a structured program at least eight hours per day, five days per week; or • The mental and/or chemical healthcare provider is providing a covered benefit under this policy; and Eligible mental and/or chemical healthcare providers are: • A program licensed, approved, established, maintained, contracted with, or operated by the Addictions and Mental Health Division of the Oregon Health Authority; • A medical or osteopathic physician licensed by the State Board of Medical Examiners; • A psychologist (Ph.D.) licensed by the State Board of Psychologists' Examiners; • A nurse practitioner registered by the State Board of Nursing; • A clinical social worker (L.C.S.W.) licensed by the State Board of Clinical Social Workers; SPD 0714_City of Ashland V2 091614 39 • A Licensed Professional Counselor (L.P.C) licensed by the State Board of Licensed Professional Counselors and Therapists; • A Licensed Marriage and Family Therapist (L.M.F.T) licensed by the State Board of Licensed Professional Counselors and Therapists; and • A hospital or other healthcare facility licensed by the Joint Commission on Accreditation of Hospitals or the Commission on Accreditation of Rehabilitation Facilities for inpatient or residential care and treatment of mental health conditions and/or chemical dependency. Medical Necessity and Appropriateness of Treatment • As with all medical treatment, mental health and chemical dependency treatment is subject to review for medical necessity and/or appropriateness. Review of treatment may involve pre-service review, concurrent review of the continuation of treatment, post-treatment review, or a combination of these. PacificSource will notify the patient and patient's provider when a treatment review is necessary to make a determination of medical necessity. • A second opinion may be required for a medical necessity determination. PacificSource will notify the patient when this requirement is applicable. • PacificSource must be notified of an emergency admission within two business days. • Medication management by an M.D. (such as a psychiatrist) does not require review. • Treatment of substance abuse and related disorders is subject to placement criteria established by the American Society of Addiction Medicine. Mental Health Parity and Addiction Equity Act of 2008 This group health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. HOME HEALTH AND HOSPICE SERVICES • This plan covers home health services up to 180 visits per benefit year when preauthorized by PacificSource. Covered services include skilled nursing by a R.N. or L.P.N.; physical, occupational, and speech therapy; and medical social work services provided by a licensed home health agency. Private duty nursing is not covered. • Home infusion services are covered when preauthorized by PacificSource. This benefit covers parenteral nutrition, medications, and biologicals (other than immunizations) that cannot be self- administered. Benefits are paid at the percentage stated in your Medical Benefit Summary for home health care. • This plan covers hospice services when preauthorized by PacificSource. Hospice services are intended to meet the physical, emotional, and spiritual needs of the patient and family during the final stages of illness and dying, while maintaining the patient in the home setting. Services are intended to supplement the efforts of an unpaid caregiver. Hospice benefits do not cover services of a primary caregiver such as a relative or friend, or private duty nursing. PacificSource uses the following criteria to determine eligibility for hospice benefits: The member's physician must certify that the member is terminally ill with a life expectancy of less than six months; The member must be living at home; A non-salaried primary caregiver must be available and willing to provide custodial care to the member on a daily basis; and The member must not be undergoing treatment of the terminal illness other than for direct control of adverse symptoms. Only the following hospice services are covered: - Home nursing visits. - Home health aides when necessary to assist in personal care. Home visits by a medical social worker. - Home visits by the hospice physician. - Prescription medications for the relief of symptoms manifested by the terminal illness. SPD 0714_City of Ashland V2 091614 40 - Medically necessary physical, occupational, and speech therapy provided in the home. Home infusion therapy. Durable medical equipment, oxygen, and medical supplies. - Respite care provided in a nursing facility to provide relief for the primary caregiver, subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days. A member must be enrolled in a hospice program to be eligible for respite care benefits. Inpatient hospice care when provided by a Medicare-certified or state-certified program when admission to an acute care hospital would otherwise be medically necessary. - Pastoral care and bereavement services. The member retains the right to all other services provided under this contract, including active treatment of non-terminal illnesses, except for services of another provider that duplicate the services of the hospice team. DURABLE MEDICAL EQUIPMENT • This plan covers prosthetic and orthotic devices that are medically necessary to restore or maintain the ability to complete activities of daily living or essential job-related activities and that are not solely for comfort or convenience. Benefits include coverage of all services and supplies medically necessary for the effective use of a prosthetic or orthotic device, including formulating its design, fabrication, material and component selection, measurements, fittings, static and dynamic alignments, and instructing the patient in the use of the device. Benefits also include coverage for any repair or replacement of a prosthetic or orthotic device that is determined medically necessary to restore or maintain the ability to complete activities of daily living or essential job-related activities and that is not solely for comfort or convenience. • This plan covers durable medical equipment prescribed exclusively to treat medical conditions. Covered equipment includes crutches, wheelchairs, orthopedic braces, home glucose meters, equipment for administering oxygen, and non-power assisted prosthetic limbs and eyes. Durable medical equipment must be prescribed by a licensed M.D., D.O., N.P., P.A., D.D.S., D.M.D., or D.P.M. to be covered. This plan does not cover equipment commonly used for nonmedical purposes, for physical or occupational therapy, or prescribed primarily for comfort. Please see 'Excluded Services - Equipment and Devices' in the Benefit Limitations and Exclusions section for information on items not covered. The following limitations apply to durable medical equipment: - This benefit covers the cost of either purchase or rental of the equipment for the period needed, whichever is less. Repair or replacement of equipment is also covered when necessary, subject to all conditions and limitations of the plan. If the cost of the purchase, rental, repair, or replacement is over $800, preauthorization by PacificSource is required. - Only expenses for durable medical equipment, or prosthetic and orthotic devices that are provided by a PacificSource contracted provider or a provider that satisfies the criteria of the Medicare fee schedule for Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description are eligible for reimbursement. Mail order or Internet/Web based providers are not eligible providers. - Purchase, rental, repair, lease, or replacement of a power-assisted wheelchair (including batteries and other accessories) requires preauthorization by PacificSource and is payable only in lieu of benefits for a manual wheelchair. - The durable medical equipment benefit also covers lenses to correct a specific vision defect resulting from a severe medical or surgical problem, such as stroke, neurological disease, trauma, or eye surgery other than refraction procedures. Coverage is subject to the following limitations: o The medical or surgical problem must cause visual impairment or disability due to loss of binocular vision or visual field defects (not merely a refractive error or astigmatism) that requires lenses to restore some normalcy to vision. o The maximum allowance for glasses (lenses and frames), or contact lenses in lieu of glasses, is limited to $200 per initial case. 'Initial case' is defined as the first time surgery or treatment is performed on either eye. Other policy limitations, such as exclusions for extra lenses, other hardware, tinting of lenses, eye exercises, or vision therapy, also apply. SPD 0714_City of Ashland V2 091614 41 0 Benefits for subsequent medically necessary vision corrections to either eye (including an eye not previously treated) are limited to the cost of lenses only. Reimbursement is subject to the deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable medical equipment and is in lieu of, and not in addition to benefits payable under any vision endorsement that may be added to this plan. The durable medical equipment benefit also covers hearing aids for members under 18 years of age and younger, or 25 years of age and younger if the member is enrolled in a secondary school or an accredited educational institution. Coverage is limited to a maximum benefit of $4,000 every 48 months. The benefit amount may be adjusted on January 1 of each year to reflect the U.S City Average Consumer Price Index. Medically necessary treatment for sleep apnea and other sleeping disorders is covered when preauthorized by PacificSource. Coverage of oral devices includes charges for consultation, fitting, adjustment, follow-up care, and the appliance. The appliance must be prescribed by a physician specializing in evaluation and treatment of obstructive sleep apnea, and the condition must meet criteria for obstructive sleep apnea. Wigs following chemotherapy or radiation therapy are covered up to a maximum benefit of $150 per benefit year. Breastfeeding pumps, manual and electric, are covered at no cost per pregnancy when purchased or rented from a licensed provider, or purchased from a retail outlet. Hospital- grade breast pumps are excluded under preventive care and regular benefits. TRANSPLANT SERVICES This plan covers certain medically necessary organ and tissue transplants. It also covers the cost of acquiring organs or tissues needed for covered transplants and limited travel expenses for the patient, subject to certain limitations. All pre-transplant evaluations, services, treatments, and supplies for transplant procedures require preauthorization by PacificSource. You must have been covered under this plan for at least 24 consecutive months or since birth to be eligible for transplant benefits, including benefits for transplantation evaluation. See Exclusion Periods - Transplants in the Benefit Limitations and Exclusions section of this Summary Plan Description for details. This plan covers the following medically necessary organ and tissue transplants: • Kidney • Kidney - Pancreas • Pancreas whole organ transplantation (under certain criteria) • Heart • Heart - Lung • Lung • Liver (under certain criteria) • Bone marrow and peripheral blood stem cell • Pediatric bowel This plan only covers transplants of human body organs and tissues. Transplants of artificial, animal, or other non-human organs and tissues are not covered. Expenses for the acquisition of organs or tissues for transplantation are covered only when the transplantation itself is covered under this contract, and is subject to the following limitations: • Testing of related or unrelated donors for a potential living related organ donation is payable at the same percentage that would apply to the same testing of an insured recipient. • Expense for acquisition of cadaver organs is covered, payable at the same percentage and subject to the same maximum dollar limitation, if any, as the transplant itself. SPD 0714_City of Ashland V2 091614 42 • Medical services required for the removal and transportation of organs or tissues from living donors are covered. Coverage of the organ or tissue donation is at the same percentage payable for the transplant itself up to $8,000 if the donor is a member of this plan, and applies to the maximum dollar limitation for the transplant, if any. If the donor is not a PacificSource member, only those complications of the donation that occur during the initial hospitalization are covered up to $8,000, and such complications are covered only to the extent that they are not covered by another health plan or government program. Coverage is at the same percentage payable for the transplant itself, and also applies to the maximum dollar limitation, if any, for the transplant. If the donor is a PacificSource member, complications of the donation are covered as any other illness would be covered, up to $8,000 (as outlined above). • Transplant related services, including HLA typing, sibling tissue typing, and evaluation costs, are considered transplant expenses and accumulate toward any transplant benefit limitations and are subject to PacificSource's provider contractual agreements (see Payment of Transplant Benefits, below). Travel and housing expenses for the recipient are limited to $5,000 per transplant. Travel and living expenses are not covered for the donor. Payment of Transplant Benefits If a transplant is performed at a participating Center of Excellence transplantation facility, covered charges of the facility are subject to plan deductibles (co-insurance and co-payment amounts after deductible are waived). If PacificSource's contract with the facility includes the services of the medical professionals performing the transplant (such as physicians, nurses, and anesthesiologists), those charges are also subject to plan deductibles (co-insurance and co-payment amounts after deductible are waived). If the professional fees are not included in PacificSource's contract with the facility, then those benefits are provided according to your Medical Benefit Summary. If transplant services are available through a contracted transplantation facility but are not performed at a contracted facility, you are responsible for satisfying any deductibles or co-payments stated in your Medical Benefit Summary. This plan then pays at of 60% of the UCR after deductible and co-payments. Services of non-participating medical professionals are paid at the non-participating provider benefit level percentages and do not apply to the out-of-pocket maximum. OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS • This plan covers services of a state certified ground or air ambulance when private transportation is medically inappropriate because the acute medical condition requires paramedic support. Benefits are provided for emergency ambulance service and/or transport to the nearest facility capable of treating the condition. Air ambulance service is covered only when ground transportation is medically or physically inappropriate. Reimbursement to nonparticipating air ambulance services are based on 125% of the Medicare allowance. In some cases Medicare allowance may be significantly lower than the provider's billed amount. The provider may hold you responsible for the amount they bill in excess of the Medicare allowance, as well as applicable deductibles and co- insurance. Medically necessary travel, other than transportation by a licensed ambulance service, to the nearest facility qualified to treat the patient's medical condition is covered when approved in advance by PacificSource. • This plan covers biofeedback to treat migraine headaches or urinary incontinence when provided by an otherwise eligible practitioner. • This plan covers blood transfusions, including the cost of blood or blood plasma. • This plan covers removal, repair, or replacement of an internal breast prosthesis due to a contracture or rupture, but only when the original prosthesis was for a medically necessary mastectomy. Preauthorization by PacificSource is required, and eligibility for benefits is subject to the following criteria: - The contracture or rupture must be clinically evident by a physician's physical examination, imaging studies, or findings at surgery. - This plan covers removal, repair, and/or replacement of the prosthesis; a new reconstruction is not covered. SPD 0714_City of Ashland V2 091614 43 Removal, repair, and/or replacement of the prosthesis is not covered when recommended due to an autoimmune disease, connective tissue disease, arthritis, allergenic syndrome, psychiatric syndrome, fatigue, or other systemic signs or symptoms. - PacificSource may require a signed loan receipt/subrogation agreement before providing coverage for this benefit. • This plan covers breast reconstruction in connection with a medically necessary mastectomy. Coverage is provided in a manner determined in consultation with the attending physician and patient for: - All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; - Prostheses; and - Treatment of physical complications of the mastectomy, including lymphedema Benefits for breast reconstruction are subject to all terms and provisions of the plan, including deductibles, co-payments and/or co-insurance stated in your Medical Benefit Summary. • This plan covers cardiac rehabilitation as follows: - Phase I (inpatient) services are covered under inpatient hospital benefits. - Phase II (short-term outpatient) services are covered subject to the deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for outpatient hospital benefits. Benefits are limited to services provided in connection with a cardiac rehabilitation exercise program that does not exceed 36 sessions and that are considered reasonable and necessary. Phase III (long-term outpatient) services are not covered. • This plan covers IUD, diaphragm, Norplant and cervical cap contraceptive devices along with their insertion or removal. Contraceptive devices that can be obtained over the counter or without a prescription, such as condoms are not covered. • This plan covers corneal transplants. Preauthorization is not required. • In the following situations, this plan covers one attempt at cosmetic or reconstructive surgery: - When necessary to correct a functional disorder; or - When necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or - When necessary to correct a scar or defect on the head or neck that resulted from a covered surgery. Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred. Preauthorization by PacificSource is required for all cosmetic and reconstructive surgeries covered by this plan. For information on breast reconstruction, see 'breast prosthesis' and 'breast reconstruction' in this section. • This plan covers dental and orthodontic services for the treatment of craniofacial anomalies when medically necessary to restore function. Coverage includes but is not limited to physical disorders identifiable at birth that affect the bony structures of the face or head, such as cleft palate, cleft lip, craniosynostosis, craniofacial microsomia and Treacher Collins syndrome. Coverage is limited to the least costly clinically appropriate treatment. Cosmetic procedures and procedures to improve on the normal range of functions are not covered. See the exclusions for cosmetic/reconstructive services, dental examinations and treatment, jaw surgery, and orthognathic surgery under the 'Excluded Services' section • This plan provides coverage for certain diabetic supplies and training as follows: Diabetic supplies other than insulin and syringes (such as lancets, test strips, and glucostix) are covered subject to the deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable medical equipment. You may purchase those supplies from any retail outlet and send your receipts to PacificSource, along with your name, group number, and member ID number. PacificSource will process the claim and mail you a reimbursement check. SPD 0714_City of Ashland V2 091614 44 Diabetic insulin and syringes are covered under your prescription drug benefit, if your plan includes prescription coverage. Lancets and test strips are also available under that prescription benefit in lieu of those covered supplies under the medical plan. This plan covers one diabetes self-management education program at the time of diagnosis, and up to three hours of education per year if there is a significant change in your condition or its treatment. To be covered, the training must be provided by an accredited diabetes education program, or by a physician, registered nurse, nurse practitioner, certified diabetes educator, or licensed dietitian with expertise in diabetes. - This plan covers medically necessary telemedical health services provided in connection with the treatment of diabetes (see Professional Services in this section). • This plan covers dietary or nutritional counseling provided by a registered dietitian under certain circumstances. It is covered under the diabetic education benefit, or for management of inborn errors of metabolism (excluding obesity), or for management of anorexia nervosa or bulimia nervosa (to a lifetime maximum of five visits). • This plan covers nonprescription elemental enteral formula ordered by a physician for home use. Formula is covered when medically necessary to treat severe intestinal malabsorption and the formula comprises a predominant or essential source of nutrition. Coverage is subject to the deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable medical equipment. • This plan covers routine foot care for patients with diabetes mellitus. • Hospitalization for dental procedures is covered when the patient has another serious medical condition that may complicate the dental procedure, such as serious blood disease, unstable diabetes, or severe cardiovascular disease, or the patient is physically or developmentally disabled with a dental condition that cannot be safely and effectively treated in a dental office. Coverage requires preauthorization by PacificSource, and only charges for the facility, anesthesiologist, and assistant physician are covered. Hospitalization because of the patient's apprehension or convenience is not covered. • This plan covers treatment for inborn errors of metabolism involving amino acid, carbohydrate, and fat metabolism for which widely accepted standards of care exist for diagnosis, treatment, and monitoring exist, including quantification of metabolites in blood, urine or spinal fluid or enzyme or DNA confirmation in tissues. Coverage includes expenses for diagnosing, monitoring and controlling the disorders by nutritional and medical assessment, including but not limited to clinical visits, biochemical analysis and medical foods used in the treatment of such disorders. Nutritional supplies are covered subject to the deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable medical equipment. • Injectable drugs and biologicals administered by a physician are covered when medically necessary for diagnosis or treatment of illness or injury. This benefit does not include immunizations (see Preventive Care Services in this section) or drugs or biologicals that can be self-administered or are dispensed to a patient. • This plan covers maxillofacial prosthetic services when prescribed by a physician as necessary to restore and manage head and facial structures. Coverage is provided only when head and facial structures cannot be replaced with living tissue, and are defective because of disease, trauma, or birth and developmental deformities. To be covered, treatment must be necessary to control or eliminate pain or infection or to restore functions such as speech, swallowing, or chewing. Coverage is limited to the least costly clinically appropriate treatment, as determined by the physician. Cosmetic procedures and procedures to improve on the normal range of functions are not covered. Dentures, prosthetic devices for treatment of TMJ conditions, and artificial larynx are also not covered. • Pediatric dental care is not covered. • The routine costs of care associated with approved clinical trials are covered. Benefits are only provided for routine costs of care associated with approved clinical trials. Expenses for services or supplies that are not considered routine costs of care are not covered. For more information, see 'routine costs of care' in the Definitions section of this Summary Plan Description. A'qualified individual' is someone who is eligible to participate in a qualifying clinical trial. If a participating provider is participating in an approved clinical trial, the qualified individual may be required to participate in the trial through that participating provider if the provider will accept the individual as a participant in the trial. SPD 0714_City of Ashland V2 091614 45 • Sleep studies are covered when ordered by a pulmonologist, neurologist, otolaryngologist, or certified sleep medicine specialist, and when performed at a certified sleep laboratory. • This plan covers medically necessary therapy and services for the treatment of traumatic brain injury. • This plan covers tubal ligation and vasectomy procedures with no waiting period. BENEFIT LIMITATIONS AND EXCLUSIONS Least Costly Setting for Services Covered services must be performed in the least costly setting where they can be provided safely. If a procedure can be done safely in an outpatient setting but is performed in a hospital inpatient setting, this plan will only pay what it would have paid for the procedure on an outpatient basis. If services are performed in an inappropriate setting, your benefits can be reduced by up to 30 percent or $2,500, whichever is less. EXCLUDED SERVICES A Note About Optional Benefits If your Plan Sponsor provides coverage for optional benefits such as prescription drugs, vision services, chiropractic care, or alternative care, you'll find those Member Benefit Summaries in this Summary Plan Description. If your Plan Sponsor provides optional benefits for an exclusion listed below, then the exclusion does not apply to the extent that coverage exists under the optional benefit. For example, if your Plan Sponsor provides optional chiropractic coverage, then the exclusion for chiropractic care listed below under 'Types of Treatment' does not apply to you. Types of Treatment- This plan does not cover the following: • Acupuncture • Chelation therapy including associated infusions of vitamins and/or minerals, except as medically necessary for the treatment of selected medical conditions and medically significant heavy metal toxicities • Day care or custodial care - Care and related services designed essentially to assist a person in maintaining activities of daily living, e.g. services to assist with walking, getting in/out of bed, bathing, dressing, feeding, preparation of meals, homemaker services, special diets, rest cures, day care, and diapers. Custodial care is only covered in conjunction with respite care allowed under this plan's hospice benefit. For related provisions, see 'Hospital and Skilled Nursing Facility Services' and 'Home Health and Hospice Services' in the Covered Expenses section of this Summary Plan Description. • Dental examinations and treatment, which means any services or supplies to prevent, diagnose, or treat diseases of the teeth and supporting tissues or structures, except as specified in Covered Expenses - Preventive Care Services except as specifically provided with a separate PacificSource Dental Plan (See the Dental Benefit Plan section of this Summary Plan Description). • Eye exercises, therapy, and procedures - Orthoptics, vision therapy, and procedures intended to correct refractive errors • Fitness or exercise programs and health or fitness club memberships • Foot care (routine) - Services and supplies for corns and calluses of the feet, conditions of the toenails other than infection, hypertrophy or hyperplasia of the skin of the feet, and other routine foot care, except in the case of patients being treated for diabetes mellitus • Genetic (DNA) testing, except for tests identified as medically necessary for the diagnosis and standard treatment of specific diseases • Homeopathic treatment • Infertility - Services and supplies, surgery, treatment, or prescriptions to prevent, or cure infertility or to induce fertility (including Gamete and/or Zygote Interfallopian Transfer; i.e. GIFT or ZIFT), except for medically necessary medication to preserve fertility during treatment with cytotoxic chemotherapy. For related provisions, see the exclusion for 'family planning' in this section. For purposes of this plan, infertility is defined as: SPD 0714_City of Ashland V2 091614 46 o Male: Low sperm counts or the inability to fertilize an egg o Female: The inability to conceive or carry a pregnancy to 12 weeks • Instructional or educational programs, except diabetes self-management programs • Jaw - Services or supplies for developmental or degenerative abnormalities of the jaw, malocclusion, dental implants, or improving placement of dentures. • Massage, massage therapy, or neuromuscular re-education, even as part of a physical therapy program • Motion analysis, including videotaping and 3-D kinematics, dynamic surface and fine wire electromyography, and physician review • Myeloablative high dose chemotherapy, except when the related transplant is specifically covered under the transplantation provisions of this plan. For related provisions, see 'Transplant Services' in the Covered Expenses section of this Summary Plan Description. • Naturopathic treatment • Obesity or weight control - Surgery or other related services or supplies provided for weight control or obesity (including all categories of obesity) except as listed under 'Preventive Care Services', whether or not there are other medical conditions related to or caused by obesity. This also includes services or supplies used for weight loss, such as food supplementation programs and behavior modification programs, regardless of the medical conditions that may be caused or exacerbated by excess weight, and self-help or training programs for weight control. Obesity screening and counseling are covered for children and adults; see the 'dietary or nutritional counseling' section under 'Other Covered Services'. • Oral/facial motor therapy for strengthening and coordination of speech-producing musculature and structures • Osteopathic manipulation, except for treatment of disorders of the musculoskeletal system • Physical or eye examinations required for administrative purposes such as participation in athletics, admission to school, or by a Plan Sponsor • Private nursing service • Programs that teach a person to use medical equipment, care for family members, or self- administer drugs or nutrition (except for diabetic education benefit) • Rehabilitation - Functional capacity evaluations, work hardening programs, vocational rehabilitation, community reintegration services, and driving evaluations and training programs • Routine services and supplies - Services, supplies, and equipment not involved in diagnosis or treatment but provided primarily for the comfort, convenience, cosmetic purpose, environmental control, or education of a patient or for the processing of records or claims. These include but are not limited to: o Missed appointments, completion of claim forms, or reports requested by PacificSource in order to process claims o Appliances, such as air conditioners, humidifiers, air filters, whirlpools, hot tubs, heat lamps, or tanning lights o Private nursing services or personal items such as telephones, televisions, and guest meals in a hospital or skilled nursing facility o Maintenance supplies and equipment not unique to medical care • Screening tests - Services and supplies, including imaging and screening exams performed for the sole purpose of screening and not associated with specific diagnoses and/or signs and symptoms of disease or of abnormalities on prior testing (including but not limited to total body CT imaging, CT colonography and bone density testing).This does not include preventive care screenings listed under 'Preventive Care Services' in the Covered Expenses section of this Summary Plan Description. • Self-help or training programs • Sexual disorders - Services or supplies for the treatment of sexual dysfunction or inadequacy unless medically necessary to treat a mental health issue and diagnosis. For related provisions, see the exclusions for 'family planning', 'infertility', and 'mental illness' in this section. SPD 0714_City of Ashland V2 091614 47 • Snoring - Services or supplies for the diagnosis or treatment of snoring or upper airway resistance disorders, including somnoplasty • Speech therapy - Oral/facial motor therapy for strengthening and coordination of speech-producing muscles and structures, except as medically necessary in the restoration or improvement of speech following a traumatic brain injury or for a child 17 years of age or younger diagnosed with a pervasive developmental disorder. • Temporomandibular joint (TMJ)-related services, or treatment for associated myofascial pain, including physical or oromyofacial therapy Surgeries and Procedures - This plan does not cover the following: • Abdominoplasty for any indication • Artificial insemination, in vitro fertilization, or GIFT procedures • Cosmetic/reconstructive services and supplies - Except as specified in the Covered Expenses - Other Covered Services, Supplies, and Treatments section of this Summary Plan Description, services and supplies, including drugs, rendered primarily for cosmetic/reconstructive purposes and any complications as a result of non-covered cosmetic/reconstructive surgery. Cosmetic/reconstructive services and supplies are those performed primarily to improve the body's appearance and not primarily to restore impaired function of the body, regardless of whether the area to be treated is normal or abnormal. • Electronic Beam Tomography (EBT) • Eye refraction procedures, orthoptics, vision therapy, or other services to correct refractive error except as indicated in the Covered Services section of this Summary Plan Description • Jaw surgery - Treatment for abnormalities of the jaw, malocclusion, or improving the placement of dentures and dental implants • Orthognathic surgery - Services and supplies to augment or reduce the upper or lower jaw, except as specified under 'Professional Services' in the Covered Expenses section of this Summary Plan Description. • Panniculectomy for any indication • Sex reassignment - Procedures, services or supplies related to a sex reassignment unless medically necessary. For related provisions, see exclusions for 'mental illness' in this section. o Excluded procedures include, but are not limited to: staged gender reassignment surgery, including breast augmentation; penile implantation; liposuction, thyroid chondroplasty, laryngoplasty, or shortening of the vocal cords, and/or hair removal specifically to assist the appearance of other characteristics of gender reassignment. • Surgery to reverse voluntary sterilization • Transplants - Any services, treatments, or supplies for the transplantation of bone marrow or peripheral blood stem cells or any human body organ or tissue, except as expressly provided under the provisions of this plan for covered transplantation expenses. For related provisions see 'Transplant Services' in the Covered Expenses section of this Summary Plan Description. Mental Health Services - This plan does not cover the following services, whether provided by a mental health or chemical dependency specialist or by any other provider: Treatment for the following diagnosis: • Diagnostic codes V 15.81 through V71.09 (DSM-IV-TR, Forth Edition) except V61.20, V61.21, and V62.82 when used with children five years of age or younger • Food dependencies • Gender Identity Disorders in Adults (GID) • Learning disorders • Mental illness does not include - Treatment of intellectual disabilities and relationship problems (e.g. parent-child, partner, sibling, or other relationship issues), except the treatment of children five years of age or younger for parent-child relational problems, physical abuse of a child, sexual abuse of a child, neglect of a child, or bereavement. This plan does not cover educational or SPD 0714_City of Ashland V2 091614 48 correctional services or sheltered living provided by a school or halfway house, except outpatient services received while temporarily living in a shelter; psychoanalysis or psychotherapy received as part of an educational or training program, regardless of diagnosis or symptoms that may be present; or a court-ordered sex offender treatment program. The following treatment types are also excluded, regardless of diagnosis: marital/partner counseling; support groups; sensory integration training; biofeedback except to treat migraine headaches or urinary incontinence; hypnotherapy; academic skills training; narcosynthesis; aversion therapy; and social skill training. Recreation therapy is only covered as part of an inpatient or residential admission. The following are also excluded: court-mandated diversion and/or chemical dependency education classes; court-mandated psychological evaluations for child custody determinations; voluntary mutual support groups such as Alcoholics Anonymous; adolescent wilderness treatment programs; mental examinations for the purpose of adjudication of legal rights; psychological testing and evaluations not provided as an adjunct to treatment or diagnosis of a stress management, parenting skills, or family education; assertiveness training; image therapy; sensory movement group therapy; marathon group therapy; sensitivity training; and psychological evaluation for sexual dysfunction or inadequacy. • Mental retardation • Nicotine related disorders • Paraphilias Treatment programs, training, or therapy as follows: • Academic skills training • Aversion therapy • Biofeedback (other than as specifically noted under the Covered Expenses - Other covered Services, Supplies, and Treatment section) • Court-ordered sex offender treatment programs • Educational or correctional services or sheltered living provided by a school or halfway house • Equine/animal therapy • Hypnotherapy • Narcosynthesis • Psychoanalysis or psychotherapy received as part of an educational or training program, regardless of diagnosis or symptoms that may be present • Marital/partner counseling • Recreation therapy outside a inpatient or residential treatment setting • Sensory integration training • Social skill training • Support groups Drugs and Medications - This plan does not cover the following: • Drugs and biologicals that can be self-administered (including injectibles), other than those provided in a hospital emergency room, or other institutional setting, or as outpatient chemotherapy and dialysis, which are covered • Growth hormone injections or treatments, except to treat documented growth hormone deficiencies • Immunizations when recommended for or in anticipation of exposure through travel or work • Over-the-counter medications or non-prescription drugs Equipment and Devices - This plan does not cover the following: • Computer or electronic equipment for monitoring asthmatic, diabetic, or similar medical conditions or related data • Equipment commonly used for nonmedical purposes - This plan does not cover the following: SPD 0714_City of Ashland V2 091614 49 o Equipment commonly used for nonmedical purposes, or marketed to the general public, or intended to alter the physical environment. This includes appliances like adjustable power beds sold as furniture, air conditioners, air purifiers, room humidifiers, heating and cooling pads, home blood pressure monitoring equipment, light boxes, conveyances other than conventional wheelchairs, whirlpool baths, spas, saunas, heat lamps, tanning lights, and pillows. It also includes orthopedic shoes and shoe modifications. Mattresses and mattress pads are only covered when medically necessary to heal pressure sores. • Equipment used primarily in athletic or recreational activities. This includes exercise equipment for stretching, conditioning, strengthening, or relief of musculoskeletal problems • Modifications to vehicles or structures to prevent, treat, or accommodate a medical condition • Personal items such as telephones, televisions, and guest meals during a stay at a hospital or other inpatient facility • Replacement costs for worn or damaged durable medical equipment that would otherwise be replaceable without charges under warranty or other agreement Experimental or Investigational Treatment Your Plan Sponsor's plan does not cover experimental or investigational treatment. By that, PacificSource means services, supplies, protocols, procedures, devices, chemotherapy, drugs or medicines or the use thereof that are experimental or investigational for the diagnosis and treatment of the patient. It includes treatment that, when and for the purpose rendered: • Has not yet received full U.S. government agency approval (e.g. FDA) for other than experimental, investigational, or clinical testing; • Is not of generally accepted medical practice in Oregon or as determined by PacificSource in consultation with medical advisors, medical associations, and/or technology resources; • Is not approved for reimbursement by the Centers for Medicare and Medicaid Services; • Is furnished in connection with medical or other research; or • Is considered by any governmental agency or subdivision to be experimental or investigational, not reasonable and necessary, or any similar finding. An experimental or investigational service is not made eligible for benefits by the fact that other treatment is considered by your healthcare provider to be ineffective or not as effective as the service or that the service is prescribed as the most likely to prolong life. When making benefit determinations about whether treatments are investigational or experimental, PacificSource relies on the above resources as well as: • Expert opinions of specialists and other medical authorities; • Published articles in peer-reviewed medical literature; • External agencies whose role is the evaluation of new technologies and drugs; and • External review by an independent review organization. The following will be considered in making the determination whether the service is in an experimental and/or investigational status: • Whether there is sufficient evidence to permit conclusions concerning the effect of the services on health outcomes; • Whether the scientific evidence demonstrates that the services improve health outcomes as much or more than established alternatives; • Whether the scientific evidence demonstrates that the services' beneficial effects outweigh any harmful effects; and • Whether any improved health outcomes from the services are attainable outside an investigational setting. If you or your provider have any concerns about whether a course of treatment will be covered, PacificSource encourages you to contact PacificSource's Customer Service Department. PacificSource will arrange for medical review of your case against PacificSource's criteria, and notify you of whether the proposed treatment will be covered. SPD 0714_City of Ashland V2 091614 50 Other Items - This plan does not cover the following: • Treatment not medically necessary - Services or supplies that are not medically necessary for the diagnosis or treatment of an illness, injury, or disease. For related provisions, see 'medically necessary' in the Definitions section and 'Understanding Medical Necessity' in the Covered Expenses section of this Summary Plan Description. • Treatment prior to enrollment - Services or supplies a member received prior to enrolling in coverage provided by this plan; charges for inpatient stays that begin before you were covered by this plan; services or supplies received before this plan's coverage began; admission prior to coverage; services and supplies for an admission to a hospital, skilled nursing facility or specialized facility that began before the patient's coverage under this plan • Treatment after coverage ends - Services or supplies received after enrollment in this policy ends. (The only exception is if this policy is replaced by another group health policy while you are hospitalized. The plan will continue paying covered hospital expenses until you are released or your benefits are exhausted, whichever occurs first.) • Care and related services designed essentially to assist a person in maintaining activities of daily living, e.g. services to assist with walking, getting in/out of bed, bathing, dressing, feeding, and preparation of meals, homemaker services, special diets, rest crew, day care, and diapers. Custodial care is only covered in conjunction with respite care allowed under this policy's hospice benefit (see Covered Expenses - Hospital, Skilled Nursing Facility, Home Health, and Hospice Services). • Services or supplies available to you from another source, including those available through a government agency • Services or supplies for which no charge is made, for which the member is not legally required to pay, or for which a provider or facility is not licensed to provide even though the service or supply may otherwise be eligible. This exclusion includes services provided by the member, or by an immediate family member. • Services or supplies for which you are not willing to release the medical or eligibility information PacificSource needs to determine the benefits paid under this plan • Charges that are the responsibility of a third party who may have caused the illness, injury, or disease or other insurers covering the incident (such as workers' compensation insurers, automobile insurers, and general liability insurers) • Charges over the usual, customary, and reasonable fee (UCR) - Any amount in excess of the UCR for a given service or supply, except alternative care. • Treatment of any illness, injury, or disease resulting from an illegal occupation or attempted felony, or treatment received while in the custody of any law enforcement authority • Treatment of any condition caused by a war, armed invasion, or act of aggression, or while serving in the armed forces • Treatment of any work-related illness or injury, unless you are the owner, partner, or principal of the Plan Sponsor, injured in the course of employment of the Plan Sponsor, and are otherwise exempt from, and not covered by, state or federal workers' compensation insurance. This includes illness or injury caused by any for-profit activity, whether through employment or self-employment. • Treatment while incarcerated - Services or supplies a member receives while in the custody of any state or federal law enforcement authorities or while in jail or prison • Charges for phone consultations, missed appointments, get acquainted visits, completion of claim forms, or reports PacificSource needs to process claims • Any amounts in excess of the allowable fee for a given service or supply • Training or self-help programs - General fitness exercise programs, and programs that teach a person how to use durable medical equipment or care for a family member. Also excluded are health or fitness club services or memberships and instruction programs, including but not limited to those to learn to self-administer drugs or nutrition, except as specifically provided for in this plan. • Services of providers who are not eligible for reimbursement under this plan. An individual organization, facility, or program is not eligible for reimbursement for services or supplies, regardless of whether this plan includes benefits for such services or supplies, unless the individual, organization, facility, or program is licensed by the state in which services are provided SPD 0714_City of Ashland V2 091614 51 as an independent practitioner, hospital, ambulatory surgical center, skilled nursing facility, durable medical equipment supplier, or mental and/or chemical healthcare facility. And to the extent PacificSource maintains credentialing requirements the practitioner or facility must satisfy those requirements in order to be considered an eligible provider. • Scheduled and/or non-emergent medical care outside of the United States. • Services otherwise available - These include but are not limited to: o Services or supplies for which payment could be obtained in whole or in part if the member applied for payment under any city, county, state (except Medicaid), or federal law; and o Services or supplies the member could have received in a hospital or program operated by a federal government agency or authority, except otherwise covered expenses for services or supplies furnished to a member by the Veterans' Administration of the United States that are not military service-related. This exclusion does not apply to covered services provided through Medicaid or by any hospital owned or operated by the State of Oregon or any state-approved community mental health and developmental disability program. • Benefits not stated - Services and supplies not specifically described as benefits under the group health policy and/or any endorsement attached hereto EXCLUSION PERIODS Exclusion Period for Transplant Benefits Except for corneal transplants, organ and tissue transplants are not covered until you have been enrolled in this plan for 24 months or since birth. If you were covered under another health insurance plan before enrolling in this plan, you can receive credit for your prior coverage. See the Credit for Prior Coverage section, below. CREDIT FOR PRIOR COVERAGE You can receive credit toward this plan's exclusion periods if you had qualifying healthcare coverage before enrolling in this plan. To qualify for this credit, there may not have been more than a 63-day gap between your last day of coverage under the previous health plan and your first day of coverage (or the first day of your Plan Sponsor's probationary waiting period) under this plan. Your prior coverage must have been a group health plan, COBRA or state continuation coverage, individual health policy (including student plans), Medicare, Medicaid, TRICARE, State Children's Health Insurance Program, and coverage through high risk pools and the Peace Corps. If you were covered as a dependent under a plan that meets these qualifications, you will qualify for credit. Many people elect the COBRA or state continuation coverage available under a prior plan to make sure they won't have more than a 63-day gap in coverage. It is your responsibility to show you had creditable coverage. If you qualify for credit, PacificSource will count every day of coverage under your prior plan toward this plan's exclusion periods for pre- existing conditions, other specified conditions, and transplants (explained above). Evidence of Prior Creditable Coverage You can show evidence of creditable coverage by sending PacificSource a Certificate of Creditable Coverage from your previous health plan. All health plans, insurance companies, and HMOs are required by law to provide these certificates on request. Most insurers issue these certificates automatically whenever someone's coverage ends. The certificate shows how long you were covered under your previous plan and when your coverage ended. If you do not have a certificate of prior coverage, contact your previous insurance company or Plan Sponsor (such as your former employer, if you had a group health plan). You have the right to request a certificate from any prior plan, insurer, HMO, or other entity through which you had creditable coverage. If you are unable to obtain a certificate, contact PacificSource's Membership Services Department for assistance. SPD 0714_City of Ashland V2 091614 52 HEALTH CARE MANAGEMENT AND PREAUTHORIZATION What is Health Care Management Your Plan Sponsor desires to provide you and your family with a heath care benefit plan that financially protects you from significant health care expenses and assures you quality care. While part of increasing health care costs results from new technology and important medical advances, another significant cause is the way health care services are used. Some studies indicate that a high percentage of the cost for health care services may be unnecessary. For example, hospital stays may be longer than necessary. Some hospitalizations may be entirely avoidable, such as when surgery could be performed at an outpatient facility with equal quality and safety. Also, surgery is sometimes performed when other treatment could be more effective. All of these instances increase costs for you and the plan. Your Plan Sponsor has contracted with PacificSource to assist you in determining whether or not proposed services are appropriate for reimbursement under this plan. The program is not intended to diagnose or treat medical conditions, dictate a treatment plan, guarantee benefits, or validate eligibility. The medical professionals who conduct the program focus their review on the appropriateness for reimbursement of hospital stays and proposed surgical procedures. Required Admission Review - You are required to call PacificSource's toll-free number, (888) 977- 9299, prior to any elective inpatient stay or any scheduled surgical procedure. In most cases, your medical provider will make the call for you. You must also call within 48 hours of any emergency admission. When you or your provider call, it will be necessary to provide the program with your name, the patient's name, the name of the physician or practitioner and hospital, the reason for the hospitalization and any other information needed to complete the review. In some cases, you may be asked for more information or a second opinion may be required to complete the review. Preauthorization - Preauthorization is necessary to determine if certain services and supplies are covered under this plan and if you meet the plan's eligibility requirements. PacificSource reviews new technologies and standards of medical practice on an ongoing basis and therefore the list of preauthorization requirements is subject to changes and updates. The current list of procedures and services that require preauthorization under the plan can be found the PacificSource' website: PacificSource.com. The list of services that require preauthorization is not intended to suggest that all the items included are necessarily covered by the benefits of this plan. A request for preauthorization must be made to PacificSource as soon as the patient knows that he or she will be receiving services for which preauthorization is required. Your medical provider can request preauthorization from PacificSource by phone - (888) 977-9299, fax - (541) 684-5264, or mail: PacificSource Health Plans PO Box 7068, Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 Espanol (800) 624-6052, extension 1009 cs@pacificsource.com If your provider will not request preauthorization for you, you may contact PacificSource yourself. In some cases, you may be asked for more information or be required to obtain a second opinion before a benefit determination can be made. If you are preauthorized for one facility, but are then transferred to another facility you will need to obtain preauthorization for the new facility before transferring, except in the case of emergencies in which case notification must be made as soon as possible after transferring facilities. If your provider's preauthorization request is denied as not medically necessary or as experimental, your provider may appeal the adverse benefit determination. You retain the right to appeal the adverse benefit determination independent from your provider. Note: A preauthorization determination is valid for 90 days. However, if your coverage under the plan ends before the services are rendered or supplies received, the preauthorization determination will become invalid. SPD 0714_City of Ashland V2 091614 53 Case Management The primary objective of large case management is to identify and coordinate cost-effective medical care alternatives and to help manage the care of patients who have special or extended care illnesses or injuries. Large case management also monitors the care of the patient, offers emotional support to the family, and coordinates communications among health care providers, patients and others. Benefits may be modified by the Plan Sponsor to permit a method of treatment not expressly provided for, but not prohibited by law, rules or public policy, if the Plan Sponsor determines that such modification is medically necessary and is more cost-effective than continuing a benefit to which you or your eligible dependents may otherwise be entitled. The Plan Sponsor also reserves the right to limit payment for services to those amounts which would have been charged had the service been provided in the most cost-effective setting in which the service could safely have been provided. Examples of illnesses or injuries that may be appropriate for large case management include, but are not limited to: • Terminal illnesses (Cancer, AIDS, Multiple Sclerosis, Renal Failure, Obstructive Pulmonary Disease, Cardiac conditions, etc.) • Accident victims requiring long-term rehabilitative care • Newborns with high-risk complications or multiple birth defects • Diagnoses involving long-term IV therapy • Illnesses not responding to medical care • Child and adolescent mental/nervous disorders • Organ transplants Individual Benefits Management Individual benefits management addresses, as an alternative to providing covered services, PacificSource's consideration of economically justified alternative benefits. The decision to allow alternative benefits will be made by on a case-by-case basis. The determination to cover and pay for alternative benefits for an individual shall not be deemed to waive, alter or affect the Plan Sponsor's or PacificSource's right to reject any other or subsequent request or recommendation. The Plan Sponsor may provide alternative benefits if PacificSource and the individual's attending provider concur in the request for and in the advisability of alternative benefits in lieu of specified covered services, and, in addition, PacificSource concludes that substantial future expenditures for covered services for the individual could be significantly diminished by providing such alternative benefits under the individual benefit management program (See Case Management above). HOW TO USE YOUR DENTAL PLAN When you need dental care, you may visit any dentist. Most dental offices will bill PacificSource directly. If your dentist has any questions regarding billing procedures, he or she can call PacificSource at (541) 225-1981, or (866) 373-7053 from outside the Eugene-Springfield area. When you first visit your dentist after becoming covered under this plan, let the office staff know you have dental benefits through PacificSource. You will need to show your PacificSource ID card, which contains your group number and benefit information. Your dentist may submit claims and treatment programs on a standard American Dental Association form. For extensive dental work, PacificSource recommends that your dentist submit a pre-treatment estimate to PacificSource. PacificSource then determines how much your plan will pay toward the proposed treatment and review the estimate with your dentist prior to treatment. If your covered family members require extensive dental work, be sure your member ID number and group number are included on their pre-treatment form for identification purposes. DENTAL PLAN BENEFITS When this plan pays for dental services, it actually pays the stated percentage of charges based on reasonable and customary charges. A charge is reasonable and customary when it falls within a general range of charges being made by most dental providers in your service area for similar SPD 0714_City of Ashland V2 091614 54 treatment of similar dental conditions. If the charge for a treatment or service is more than the reasonable and customary charge in your service area, you may be required to pay the difference. The reasonable and customary charge for dental expense is the 'covered charge' referred to in this booklet. If you or your covered family member selects a more expensive treatment than is customarily provided, this plan will pay the applicable percentage of the lesser fee. You will be responsible for the balance of the provider's charges. With the Advantage Network, participating dentists agree to write off any charges over and above the negotiated, contracted fees for most services. When you use a participating dentist in the Advantage Network, you will not be responsible for any excess charges and will pay only your plan's deductible and/or co-insurance amount. If you choose not to use a participating Advantage Network dentist, or don't have access to them, reimbursement will continue to be based on usual, customary, and reasonable (UCR) charges. If that non-participating dentist's fees exceed the UCR charges, the excess charges are also your responsibility COVERED DENTAL SERVICES This dental plan covers the following services when performed by an eligible provider and when determined to be necessary by the standards of generally accepted dental practice for the prevention or treatment of oral disease or for accidental injury, including masticatory function. Covered services may also be provided by a dental hygienist or denturist to the extent that he or she is operating within the scope of his or her license as required under law in the State of Oregon. Covered dental services are organized into three classes, starting with preventive care and advancing into specialized dental procedures. Class / Services - Diagnostic and Preventive Treatment • Examinations (routine or other diagnostic exams) are covered. Separate charges for review of a proposed treatment plan or for diagnostic aids such as study models and certain lab tests are not covered. • Full mouth x-rays and/or panorex are covered up to one complete mouth series and/or panorex in any three-year period and limited to four bite-wing films in a six-month period. When an accumulative charge for additional periapical x-rays in a one-year period matches that of a complete mouth series, no further benefits for periapical x-rays or panorex are available for the remainder of the year. • Dental cleanings (prophylaxis and periodontal maintenance) are covered to a combined total of three procedures per person per benefit year. The limitation for dental cleaning applies to any combination of prophylaxis and/or periodontal maintenance in the benefit year. A separate charge for periodontal charting is not a covered benefit. Periodontal maintenance is not covered when performed within three months of periodontal scaling and root planing and/or curettage. • Topical applications of fluoride are covered to two applications per benefit year through age 22. • Fluoride varnish applications are covered to 12 applications per benefit year for children age 12 and under if the child is deemed at risk for dental infection. • The application of sealants is covered to one application in a five-year period to permanent molars and bicuspids and only for individuals through age 17. • Vizilite is a covered up to two screenings per benefit year. • Benefits for athletic mouth guards are limited to one per lifetime through age 17 if the member is still in secondary school. • Benefits for brush biopsies used to aid in the diagnosis of oral cancer are covered. Class Restorative Services - Basic and Restorative Treatment • Composite, resin, or similar restoration in a posterior (back) tooth is covered to the amount that would be paid for a corresponding amalgam restoration. A separate charge for anesthesia when used during restorative procedures is not a covered benefit. Only one filling is allowed per tooth surface. The Plan Sponsorwill pay for a filling on a tooth surface only once per benefit year. Three or more surface fillings are limited to one per surface per benefit year. • Simple and surgical extractions of teeth and other minor oral surgery procedures are covered. SPD 0714-City of Ashland V2 091614 55 General anesthesia used in conjunction with these extractions administered by a dentist in a dental office is also covered. A separate charge for alveolectomy performed in conjunction with removal of teeth is not a covered benefit. • Periodontal scaling and root planing and/or curettage is covered but limited to only one procedure per quadrant in any 24-month period. For the purpose of this limitation, eight or fewer teeth existing in one arch will be considered one quadrant. • Benefits for full mouth debridement are limited to once every 24 months. This procedure is only covered if the teeth have not received a prophylaxis in the prior 24 months and if an evaluation cannot be performed due to the obstruction by plaque and calculus on the teeth. This procedure is not covered if performed on the same date as the prophylaxis. Class Complicated Services - Complicated Treatment • Complicated oral surgical procedures such as removal of impacted teeth are covered when preauthorized by PacificSource. Benefits for complicated oral surgical procedures include general anesthesia administered by a dentist in a dental office. A separate charge for alveolectomy performed in conjunction with removal of teeth is not a covered benefit. • Pulp capping is covered only when there is an exposure to the pulp. These are direct pulp caps. Indirect pulp caps are not covered. • Pulpotomy is covered only for deciduous teeth. • Root canal therapy is covered on the same tooth only for one charge in a three-year period. • Periodontal surgery is covered when the procedure is preauthorized by PacificSource and accompanied by a periodontal diagnosis and history of conservative (non-surgical) periodontal treatment. • Tooth desensitization is covered as a separate procedure from other dental treatment. • Space maintainers are a covered benefit for individuals through the age of 13. Class Services - Major Treatment • Crowns and other cast or laboratory-processed restorations are covered but limited to the restoration of any one tooth in a five-year period. If a tooth can be restored with a material such as amalgam or composite resin, covered charges are limited to the cost of amalgam or non-laboratory composite resin restoration even if another type of restoration is selected by the patient and/or dentist. • Replacement of an existing prosthetic device is covered only when the device being replaced is unserviceable, cannot be made serviceable, and has been in place for at least five years. • Cast partial denture, full, immediate, or overdenture are covered only to the cost of a standard full or cast partial denture. A separate charge for denture adjustments and relines performed within six months of the initial placement is not a covered benefit. Benefits for subsequent relines are provided only once in a 12-month period. Cast restorations for partial denture abutment teeth or for splinting purposes are not covered unless the tooth in and of itself requires a cast restoration. • Fixed bridges or removable cast partials are covered. Benefits for temporary full or partial dentures must be preauthorized. Benefits for the initial placement of full or partial dentures or fixed bridges (including acid-etch metal bridges) are provided only if the denture or bridgework includes replacement of a natural tooth which is extracted or lost while the member's coverage is in effect. However, this limitation does not apply after the member has been covered under the policyholder's group dental plan for a period of at least 36 consecutive months. • Benefits for the surgical placement and removal of implants are limited to once per lifetime per tooth space for each service. Services must be preauthorized by PacificSource to be covered. Benefits include final crown and implant abutment over a single implant and final implant-supported bridge abutment and implant abutment or pontic. An alternative benefit per arch of a conventional full or partial denture for the final implant-supported full or partial denture prosthetic device is available. • Bruxism splint and night guard (appliances to reduce or prevent pain or damage from grinding of teeth) are covered. SPD 0714_City of Ashland V2 091614 56 EXCLUDED DENTAL SERVICES This plan does not provide benefits in any of the following circumstances or for any of the following conditions: • Aesthetic dental procedures - Services and supplies provided in connection with dental procedures that are primarily aesthetic, including bleaching of teeth and labial veneers. • Antimicrobial agents - Localized delivery of antimicrobial agents into diseased crevicular tissue via a controlled release vehicle. • Benefits not stated - Any services and supplies not specifically described as covered benefits under this plan • Biopsies or histopathologic exams - A separate charge for a biopsy of oral tissue or histopathologic exam. • Bone replacement grafts to prepare sockets for implants after tooth extraction. • Charges for broken appointments • Collection of cultures and specimens. • Connector bar or stress breaker. • Core build-ups are not covered unless used to restore a tooth that has been treated endodontically (root canal). • Cosmetic/reconstructive services and supplies - Procedures, appliances, restorations, or other services that are primarily for cosmetic purposes. This includes services or supplies rendered primarily to correct congenital or developmental malformations, including but not limited to, peg laterals, cleft palate, maxillary and mandibular (upper and lower jaw) malformation, enamel hypoplasia, and fluorosis (discoloration of teeth). However, the replacement of congenitally missing teeth is covered. • Denture replacement made by necessary by loss, theft, or breakage. • Diagnostic casts - Diagnostic casts (study models), gnathological recordings, occlusal appliances, occlusal equilibration procedures, or similar procedures. • Drugs and medications that are prescribed drugs, premedication drugs, analgesics (e.g., nitrous oxide or non-intravenous sedation), any other euphoric drugs, or any take-home medicine or supplies distributed by a provider. • Educational programs - Instructions and/or training in plaque control and oral hygiene. • Experimental or investigational procedures - Services, supplies, protocols, procedures, devices, drugs or medicines, or the use thereof that are experimental or investigational for the diagnosis and treatment of the patient. An experimental or investigational service is not made eligible for benefits by the fact that other treatment is considered by the member's dental care provider to be ineffective or not as effective as the service or that the service is prescribed as the most likely to prolong life. • Fractures of the mandible - Services and supplies provided in connection with the treatment of simple or compound fractures of the mandible. • General anesthesia except when administered by a dentist in connection with oral surgery in his/her office • Gingivetomcy, gingivoplasty or crown lengthening in conjunction with crown preparation or fixed bridge services done on the same date of service. • Hospital charges or additional fees charged by the dentist for hospital treatment • Hypnosis • Infection control - A separate charge for infection control or sterilization • Intra and extra coronal splinting - Devices and procedures for intra and extra coronal splinting to stabilize mobile teeth. • Oral Surgery treating any fractured jaw SPD 0714_City of Ashland V2 091614 57 • Orthodontic services - Treatment of malalignment of teeth and/or jaws, or any ancillary services expressly performed because of orthodontic treatment, unless your Dental Benefit Summary shows orthodontic services as a covered benefit. • Orthognathic surgery - Surgery to manipulate facial bones, including the jaw, in patients with facial bone abnormalities performed to restore the proper anatomic and functional relationship to the facial bones • Periodontal probing, charting, and re-evaluations • Photographic images. • Pin retention in addition to restoration. • Precision attachments • Pulpotomies on permanent teeth • Removal of clinically serviceable amalgam restorations to be replaced by other materials free of mercury, except with proof of allergy to mercury. • Services covered by the member's medical plan. • Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. • Services otherwise available - These include but are not limited to: - Services or supplies for which payment could be obtained in whole or in part if the member applied for payment under any city, county, state, or federal law (except Medicaid); and - Services or supplies the member could have received in a hospital or program operated by a federal government agency or authority. Covered expenses for services or supplies furnished to a member by the Veterans' Administration of the United States that are not service-related are eligible for payment according to the terms of this policy. - Services or supplies for which payment would be made by Medicare. • Services or supplies for which no charge is made which you are not legally required to pay or which a provider or facility is not licensed to provide even though the service or supply may otherwise be eligible. This includes services provided by you or an immediate family member. • Sinus lift grafts to prepare sinus site for implants. • Temporomandibular joint (TMJ) - Any services or supplies for treatment of any disturbance of the Temporomandibular joint. • Third party liability, motor vehicle liability, motor vehicle insurance coverage, workers' compensation - Any services or supplies for illness or injury for which a third party is responsible or which are payable by such third party or which are payable pursuant to applicable workers' compensation laws, motor vehicle liability, uninsured motorist, underinsured motorist, and personal injury protection insurance and any other liability and voluntary medical or dental payment insurance to the extent of any recovery received from or on behalf of such sources. • Tooth transplantation - Services and supplies provided in connection with tooth transplantation, including re-implantation from one site to another and splinting and/or stabilization. This exclusion does not relate to the re-implantation of a tooth into its original socket after it has been avulsed. • Treatment after coverage ends - Services or supplies provided after enrollment in this plan ends. The only exception is for Class III Services ordered and fitted before enrollment ends and placed within 31 days after enrollment ends. • Treatment not dentally necessary according to acceptable dental practice or treatment not likely to have a reasonably favorable prognosis. • Treatment prior to enrollment - Dental services begun before you or your family member became eligible for those services under this plan. • Treatment while incarcerated - Services or supplies received while in the custody of any state or federal law enforcement authorities or while in jail or prison. • Unwilling to release information - Charges for services or supplies for which you are unwilling to release medical or dental information necessary to determine eligibility for payment under this policy SPD 0714_City of Ashland V2 091614 58 • War-related conditions - The treatment of any condition caused by or arising out of an act of war, armed invasion, or aggression, or while in the service of the armed forces. • Work-related conditions - Services or supplies for treatment of illness or injury arising out of or in the course of employment or self-employment for wages or profit, whether or not the expense for the service or supply is paid under workers' compensation. CLAIMS PROCEDURES How to File/How to Appeal a Claim These claim procedures describe how benefit claims and appeals are made and decided under this plan. Only members or a designated authorized representative may submit claims for benefits (for themselves and on behalf of their covered dependents), and benefits will only be paid to the member or the actual provider of services. Under the following claims procedures section, the words `you' and 'your' will mean a member of the group health plan of the Plan Sponsor. You become a claimant when you make a request for a plan benefit or benefits in accordance with these claims procedures. You and your covered dependents have the right to elect group health care benefits as offered by the Plan Sponsor, and your and their rights will be determined under the plan's provisions and in conjunction with the claims and appeals procedures outlined later in this section. Claims will also be considered filed by you if communications and requests for benefits come from an individual that you have designated as your authorized representative to act on your behalf with respect to a claim. In the event that you designate an authorized representative to act on your behalf, the plan will send all notifications, requests for further information, appeal decisions, and all other communications to your authorized representative and provide you with a copy of all communications, unless you request otherwise in writing. An authorized representative may act on behalf of a claimant with respect to benefit claim or appeal under these procedures. However, no person (including a treating health care professional) will be recognized as an authorized representative until the plan receives an Designation of Authorized Representative form signed by the claimant, except that for urgent care claims the plan shall, even in the absence of a signed Designation of Authorized Representative form, recognize a health care professional with knowledge of the claimant's medical condition (e.g., the treating physician or practitioner) as the claimant's authorized representative unless the claimant provides specific written direction otherwise. A Designation of Authorized Representative form may be obtained from and completed forms must be returned to: PacificSource Health Plans PO Box 7068, Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 Espanol (800) 624-6052, extension 1009 cs@pacificsource.com An assignment for purposes of payment (e.g., to a health professional) does not constitute appointment of an authorized representative under these claims procedures. However, unless you have directed the plan otherwise, claims submitted on your behalf by a health care professional will be considered a valid claim if submitted pursuant to the guidelines outlined in these claim procedures. Any reference in these claims procedures to the claimant is intended to include the authorized representative of such claimant appointed in compliance with the above procedures. For the purposes of the claims procedures section, any reference to `days' will refer to calendar days, not business days. Questions about Your Claims PacificSource is available to listen and help with any concerns or problems you may have with resolving a claim. Because PacificSource wants you to be completely satisfied with the member services assistance you receive, a process has been established for addressing your concerns and solving your problems. If you have a concern regarding a person, a service, the quality of care, or you want to SPD 0714_City of Ashland V2 091614 59 inquire about what benefits are covered under the plan, please call PacificSource at (888) 977-9299 and explain your concern to one of their Customer Service Representatives. You may also express that concern in writing. PacificSource will do their best to resolve the matter on your initial contact. If PacificSource needs more time to review or investigate your concern, they will get back to you as soon as possible, but in any case within 30 days. They will not consider any of these communications to be a `claim' for benefits. A formal claim for benefits must meet certain other standards which are described in greater detail in these procedures. Types of Claims Pre-Service Claims - The plan subjects the receipt of benefits for some services or supplies to a preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it may in some cases be conducted on a post-service basis. Unless a response is needed sooner due to the urgency of the situation, a pre-service preauthorization review will be completed and notification made to you and your medical provider as soon as possible, generally within two working days, but no later than 15 days within receipt of the request. Urgent Care Claims - If the time period for making a non-urgent care determination could seriously jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain that cannot be adequately managed without the care or treatment that is proposed, a preauthorization review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours within receipt of the request. Concurrent Care Review - A concurrent care decision occurs when a previously approved course of treatment is reconsidered and reduced or denied, or where an extension is requested beyond the initially approved period of time or number of treatments. Inpatient hospital or rehabilitative facilities, skilled nursing facilities, intensive outpatient, and residential behavioral health care require concurrent review for a benefit determination with regard to an appropriate length of stay or duration of service. Benefit determinations will be made as soon as possible within receipt of all the information necessary to make such a determination. Post-Service Claims -A claim determination that involves only the potential payment of reimbursement of the cost of medical care that has already been provided will be made as soon as reasonably possible but no later than 30 days from the day after receiving the claim. How to File a Claim Most health care providers will file claims on your behalf. Electronically submitted claims are processed most efficiently. If unable to file electronically, you, your health care provider, or an authorized representative must file your claim using HCFA-1500 (revision 12/90 and later), UB92, or ADA (revision 12/90 and later) forms, or an itemized statement. These forms are available from your health care provider or PacificSource. A claim will be considered filed when it is received by PacificSource at the address listed below: PacificSource Health Plans PO Box 7068, Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 Espanol (800) 624-6052, extension 1009 cs@pacificsource.com The following information is required in order qualify your request for benefits as a properly submitted claim: • Plan member's name, member ID and current address; • Patient's name, member ID and address if different from the member's; • Provider's name, tax identification number, address, degree and signature; • Date(s) of service(s); • Place of service(s); • Diagnostic Code; • Procedure Codes (describes the treatment or services rendered); SPD 0714_City of Ashland V2 091614 60 • Assignment of Benefits, signed (if payment is to be made to the provider); • Release of Information Statement, signed; and • Explanation of Benefits (EOB) information if another plan is the primary payer. This plan also recognizes the following actions and submission of forms as claims: • A request by you for benefits through preauthorization in cases where use of preauthorization is required in order to obtain a particular benefit. • Requests by your formally-designated authorized representative for preauthorization in cases where use of preauthorization is required in order to obtain a particular benefit. The plan will take reasonable steps to determine whether an individual claiming to be acting on your behalf is, in fact, validly empowered to do so under the circumstances, and the plan will require that you complete and file a form identifying any person you authorize to act on your behalf with respect to a claim. However, when inquiries by a health care provider relate to payments due to the provider-rather than due to you-under participating provider contracts (where the health care provider has no recourse against you for the amounts) such inquiries by a health care provider will not be considered 'claims' by the plan. • Requests for benefits (in the case of a claim involving urgent care) by a health care provider with knowledge of your medical condition. For urgent care claims, you are not required to complete a form and formally designate a health care provider as your representative with respect to a claim. Claims must be submitted individually for each claimant. Please do not staple claims together. Send completed information to: PacificSource Health Plans PO Box 7068, Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 Espanol (800) 624-6052, extension 1009 cs@pacificsource.com If you have any questions regarding your eligibility, benefits or claims information, please call PacificSource at: (888) 977-9299. All claims for benefits must be submitted to the plan within 90 days of the date of service. If it is not possible to submit a claim within 90 days, you should submit the claim as soon as possible. In some cases the plan will accept the late claim. The plan, however, will not pay a claim that was submitted more than one year after the date of service. All submitted claims and appeals will fall into one of the categories described previously. The handling of your initial claim or later appeal will be governed, in all respects, by the appropriate category of claim or appeal, and each time your claim or appeal is examined, a new determination will be made regarding the category into which the claim or appeal falls at that particular time. Pre-service claims - Your plan subjects the receipt of benefits for some services or supplies to a preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it may in some case be conducted on a post-service basis. Unless a response is needed sooner due to the urgency of the situation, a pre-service preauthorization review will be completed and notification made to you and your medical provider as soon as possible, generally within two working days, but no later than 15 days within receipt of the request. Urgent care claims - If the time period for making a non-urgent care determination could seriously jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain that cannot be adequately managed without the care or treatment that is proposed, a preauthorization review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours of receipt of the request. Concurrent care review- Inpatient hospital or rehabilitation facilities, skilled nursing facilities, intensive outpatient, and residential behavioral healthcare require concurrent review for a benefit determination with regard to an appropriate length of stay or duration of service. Benefit determinations will be made as soon as possible but no later than one working day after receipt of all the information necessary to make such a determination. SPD 0714-City of Ashland V2 091614 61 Post-service claims - A claim determination that involves only the payment of reimbursement of the cost of medical care that has already been provided will be made as soon as reasonably possible but no later than 30 days from the day after receiving the claim. Retrospective review - A claim for benefits for which the service or supply requires a preauthorization review but was not submitted for review on a pre-service basis will be reviewed on a retrospective basis within 30 working days after receipt of the information necessary to make a claim determination. Extension of time - Despite the specified timeframes, nothing prevents the member from voluntarily agreeing to extend the above timeframes. Unless additional information is needed to process your claim, PacificSource will make every effort to meet the timeframes stated above. If a claim cannot be paid within the stated timeframes because additional information is needed, PacificSource will acknowledge receipt of the claim and explain why payment is delayed. If PacificSource does not receive the necessary information within 15 days of the delay notice, PacificSource will either deny the claim or notify you every 45 days while the claim remains under investigation. No extension is permitted for urgent care claims. Extension of time - Unless additional information is needed to process your claim, the plan will make every effort to meet the timeframes stated above. If a claim cannot be paid within the stated timeframes because additional information is needed, PacificSource will acknowledge receipt of the claim and explain why payment is delayed. If they do not receive the necessary information within 15 days of the delay notice, they will either deny the claim or notify you every 45 days while the claim remains under investigation. Adverse benefit determinations - Any denial, reduction or termination of, or failure to provide or make a payment for a benefit based on: • A determination that the member is not eligible to participate in the plan. • A determination that the benefit is not covered by the plan. • The imposing of limits, such as source-of-injury exclusions. • A determination that the benefit is experimental, investigational or not medically necessary or medically appropriate. An adverse benefit determination made to reduce or deny benefits applied for a pre-service, post- service, or concurrent care basis may be appealed in accordance with the plan's appeals procedures described later in this section. Incomplete Claims If any information needed to process a claim is missing, the claim shall be treated as an incomplete claim. Other Incomplete Claims - If a pre-service or post-service claim is incomplete, the plan may deny the claim or may take an extension of time, as described above. If the plan takes an extension of time, the extension notice shall include a description of the missing information and shall specify a timeframe, no less than 45 days, in which the necessary information must be provided. The timeframe for deciding the claim shall be suspended from the date the extension notice is received by the claimant until the date the missing necessary information is provided to the plan. If the requested information is provided, the plan shall decide the claim within the extension period specified in the extension notice. If the requested information is not provided within the time specified, the claim may be decided without that information. If you fail to follow the plan's filing procedures because your request for benefits does not: 1) identify the patient; 2) note a specific medical condition or symptom; 3) describe a specific treatment, service, or product for which approval is requested; or 4) is not sent to the correct address, you will not have submitted a claim. You will be notified orally, and/or by written notification if requested by the claimant, within 24 hours, that you have failed to follow the filing procedures, and you will be reminded of the proper filing procedures. Notification of Benefit Determination The plan will pay the benefit according to plan provisions. This may mean that less than 100% of your claim is payable by the plan. In each case where the plan pays benefits or determines that it is not responsible for your medical claim, you will receive an Explanation of Benefits which will outline the SPD 0714_City of Ashland V2 091614 62 basis for the plan's payment. If your claim is denied or payable at a level less than outlined in this Summary Plan Description, you are entitled to appeal the decision under the rules governing adverse benefit determination. Adverse Benefit Determination • Written notification will be provided to you of the plan's adverse benefit determination (as defined in the How To File A Claim section above) and will include the following: • Information sufficient to identify the claim involved, including the date of service, the health care provider, and the claim amount (if applicable), as well as how to obtain the diagnosis code, the treatment code, and the corresponding meanings of these codes. • A statement of the specific reason(s) for the decision; • Reference(s) to the specific plan provision(s) on which the determination is based; • A description of any additional material or information necessary to perfect the claim and why such information is necessary; • A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination or a statement that such information will be provided free of charge upon request; • If the determination involves scientific or clinical judgment, disclose either (a) an explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's medical circumstances, or (b) a statement that such explanation will be provided at no charge upon request; • In the case of an urgent care claim, an explanation of the expedited review methods available for such claims; and • A statement regarding the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman. Notification of the plan's adverse benefit determination on an urgent care claim may be provided orally, but written notification shall be furnished not later than three days after the oral notice. You may call the Third Party Administrator at (888) 977-9299 to discuss the adverse benefit determination if you have concerns. You may also express those concerns in writing and if needed, may submit additional information that you believe would clarify any of the circumstances that lead to the adverse benefit determination. Third Party Administrator will not consider any of these questions or clarifications to be a formal appeal unless you specifically state it as such. The process for filing a formal appeal is listed below. Your Right to Appeal You have the right to appeal an adverse benefit determination under these claims procedures. If you choose to appeal the plan's adverse benefit determination, your appeal will be governed by rules that assure you a full and fair review. If you are denied benefits based upon the plan's finding that you are/were ineligible for benefits, the denial of benefits gives you the opportunity to appeal the plan's decision. If the plan decides to reduce or terminate benefits for your previously-approved course of treatment, the plan's decision will be treated as an adverse benefit determination, and the plan will provide you reasonable advance notice of the reduction or termination to allow you to appeal the plan's decision before the benefit reduction or termination takes place. If you decide to appeal the plan's decision, you must follow the rules for appealing a plan's decision. No lawsuit can be instituted until the claimant has exhausted the plan's internal and external claims review and appeals procedures. No lawsuit can be instituted more than one year after the date of the notice to the claimant that a claim appeal has been denied. Appealing an Initial Claim Determination - You must submit a written request to the plan within 180 days of receipt of an adverse benefit determination in order to initiate an appeal. An oral request for review is acceptable for urgent care claims and may be made by calling the Third Party Administrator at (888) 977-9299 and asking the plan to register your oral appeal. SPD 0714_City of Ashland V2 091614 63 When you appeal an adverse benefit determination, the plan will provide a full and fair review which will include the following features: • You will have the opportunity to submit written comments, documents, records, and other information related to the claim. • At your request (and free of charge), you will be provided with reasonable access to (and copies of) all documents, records, and other information relevant to your claim for benefits. Included in this category are any documents, records or other information in your claim file, whether or not those materials were relied upon by the plan in making its adverse benefit determination. You also have the right to review documentation showing that the plan followed its own internal processes for ensuring appropriate decision making. • The review of your claim will take into account all comments, documents and other information without regard to whether such information was submitted or considered in the initial benefit determination. • Any appeal of an adverse benefit determination will not give deference to the initial decision on your claim, and the review will be conducted by a designated plan representative who did not make the original determination and does not report to the plan representative who made the original determination. • In deciding an appeal of any adverse benefit determination that is based on a medical judgment (including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or medically appropriate), the designated plan representative will consult with a health care professional who has appropriate training and experience in the particular field of medicine involved in the medical judgment. This health care professional will not be the same professional who was originally consulted in connection with the adverse determination; neither will this health care professional report to the health care professional who was consulted in connection with the adverse determination. The plan will uphold the findings of the independent review in responding to the appeal. • The plan will identify medical or vocational experts whose advice was obtained on behalf of the plan in connection with an adverse benefit determination of your claim, whether or not that advice was relied upon in making the benefit determination. You must first follow this appeal process before taking any outside legal action. After you submit the claim for appeal, the plan will make a decision on your appeal as follows: Appeal of Urgent Care Claims - The plan's expedited appeal process for urgent care claims will allow you to request (orally or in writing) an expedited appeal, after which, all necessary information, including the plan's benefit determination on review, will be transmitted between the plan and you by telephone, fax, or other expeditious method. You will be notified (in writing or electronically) of the benefit determination as soon as possible, but not later than 72 hours after the plan receives the request for review of the prior benefit determination. For urgent care claims you may also be able to request an independent external review take place at the same time as you pursue the plan's internal appeal process. Appeal of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will be notified (in writing or electronically) of the benefit determination within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days. Appeal of Concurrent Care Claims - For concurrent care claims, you will be notified (in writing or electronically) of the benefit determination with reasonable advance notice before the benefit reduction or termination takes place. Appeal of Post-Service Claims - For post-service claims, you will be notified (in writing or electronically) of the benefit determination within a reasonable period of time, but not later than 60 days. Denial of Claim on Appeal - If your appealed claim is denied, the plan will send you written or electronic notification that explains why your appealed claim was denied and shall include the following: • A statement of the specific reason(s) for the decision; • Reference(s) to the specific plan provision(s) on which the determination is based; SPD 0714_City of Ashland V2 091614 64 • A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination or a statement that such information will be provided free of charge upon request; • If the determination involves scientific or clinical judgment, the plan will disclose either (a) an explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's medical circumstances, or (b) a statement that such explanation will be provided at no charge upon request; and • A statement indicating your right to receive, upon request (and free of charge), reasonable access to (and copies of) all documents, records, and other information relevant to the determination. Included in this category are any documents, records or other information in your claim file, whether or not those materials were relied upon by the plan in making its adverse determination. Additional Level of Review - If you are dissatisfied with the outcome of your appeal, you may request an additional review. The City of Ashland or its designated representative is responsible for handling and for making a determination on any additional level of review. To initiate this review you should follow the same process required for an appeal. You must submit a written request for additional review within 60 days following the receipt of the appeal decision. When you submit a request for additional review of an adverse benefit determination, the plan will provide a full and fair review which will include the following features: • You will have the opportunity to submit written comments, documents, records, and other information related to the claim. • At your request (and free of charge), you will be provided with reasonable access to (and copies of) all documents, records, and other information relevant to your claim for benefits. Included in this category are any documents, records or other information in your claim file, whether or not those materials were relied upon by the plan in making its adverse benefit determination. You also have the right to review documentation showing that the plan followed its own internal processes for ensuring appropriate decision making. • The review of your claim will take into account all comments, documents and other information without regard to whether such information was submitted or considered in the initial adverse benefit determination. • Additional review will not afford deference to the appeal determination, and the review will be conducted by a designated plan representative who did not make the original determination and does not report to the plan representative who made the original determination. • In deciding an appeal of any adverse benefit determination that is based on a medical judgment (including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or medically appropriate), the designated plan representative will consult with a health care professional who has appropriate training and experience in the particular field of medicine involved in the medical judgment. This health care professional will not be the same professional who was originally consulted in connection with the adverse determination; neither will this health care professional report to the health care professional who was consulted in connection with the adverse determination. The plan will uphold the findings of the independent review in responding to the appeal. • The plan will identify medical or vocational experts whose advice was obtained on behalf of the plan in connection with an adverse benefit determination of your claim, whether or not that advice was relied upon in making the benefit determination. After you submit the claim for additional review, the plan will make a decision on your appeal as follows: Additional Review of Urgent Care Claims - The plan's expedited additional review process for urgent care claims will allow you to request (orally or in writing) an expedited review, after which, all necessary information, including the plan's benefit determination on review, will be transmitted between the plan and you by telephone, fax, or other expeditious method. You will be notified (in writing or electronically) of the benefit determination as soon as possible, but not later than 72 hours after the plan receives the request for the review. Additional Review of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will be notified (in writing or electronically) of the review outcome within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days. SPD 0714_City of Ashland V2 091614 65 Additional Review of Concurrent Care Claims - For concurrent care claims, you will be notified (in writing or electronically) of the review outcome with reasonable advance notice before the benefit reduction or termination takes place. Additional Review of Post-Service Claims - For post-service claims, you will be notified (in writing or electronically) of the review outcome within a reasonable period of time, but not later than 60 days. Denial of Claim after Additional Review - If after your request for additional review the claim is denied, the plan will send you written or electronic notification that explains why the additional review upheld the denial and shall include the following: • A statement of the specific reason(s) for the decision; • Reference(s) to the specific plan provision(s) on which the determination is based; • A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination or a statement that such information will be provided free of charge upon request; • If the determination involves scientific or clinical judgment, the plan will disclose either (a) an explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's medical circumstances, or (b) a statement that such explanation will be provided at no charge upon request; and • A statement indicating your right to receive, upon request (and free of charge), reasonable access to (and copies of) all documents, records, and other information relevant to the determination. Included in this category are any documents, records or other information in your claim file, whether or not those materials were relied upon by the plan in making its adverse determination. Independent External Review - You may have the right to have your case reviewed by an external independent review organization. Only decisions that are based on issues related to medical necessity, medical appropriateness, health care setting, level of care, or effectiveness of a covered benefit may be appealed to an external independent review organization. The plan must contract with at least three different independent external review organizations and must rotate between them on a random or circulating basis. Your request for an independent review must be made in writing to PacificSource within 180 days of the date of the final internal adverse benefit determination. You may include additional written information, which will be included with the documents PacificSource provides to the independent review organization. A final decision made by an independent review organization is binding on the Plan Sponsor. This decision is also binding on you, except to the extent other remedies are available under state or federal law. In certain instances you may be able to request an expedited review process, such as when the timeframe for completion of the internal appeals process would seriously jeopardize the life or health of the claimant or their ability to regain maximum function, or if the final adverse benefit determination concerns an admission, availability of care, continued stay or health care service for which the claimant received emergency services, but has not been discharged from a facility. Resources For Information And Assistance Assistance in Other Languages Members who do not speak English may contact PacificSource's Customer Service Department for assistance. They can usually arrange for a multilingual staff member or interpreter to speak with them in their native language. Information Available from PacificSource PacificSource makes the following written information available to you free of charge. You may contact their Customer Service Department by phone, mail, or email to request any of the following: • A directory of participating healthcare providers under your plan • Information about PacificSource's drug formulary SPD 0714_City of Ashland V2 091614 66 • A copy of PacificSource's annual report on complaints and appeals • A description (consistent with risk-sharing information required by the Centers for Medicare and Medicaid Services, formerly known as Health Care Financing Administration) of any risk-sharing arrangements PacificSource has with providers • A description of PacificSource's efforts to monitor and improve the quality of health services • Information about how PacificSource checks the credentials of PacificSource's network providers and how you can obtain the names and qualifications of your healthcare providers • Information about PacificSource's preauthorization procedures • Information about any healthcare plan offered by the Plan Sponsor Information Available from the Oregon Insurance Division The following consumer information is available from the Oregon Insurance Division: • The results of all publicly available accreditation surveys • A summary of PacificSource's health promotion and disease prevention activities • Samples of the written summaries delivered to PacificSource policyholders • An annual summary of grievances and appeals against PacificSource • An annual summary of PacificSource's quality assessment activities • An annual summary of the scope of PacificSource's provider network and accessibility of healthcare services You can request this information by contacting the Oregon Insurance Division by writing to the Oregon Insurance Division, Consumer Advocacy Unit, PO Box 14489, Salem, OR 97309-0405 or by phone at (503) 947-7984, or the toll-free message line at (888) 877-4894, on the Internet at http://insurance.oregon.gov/consumer/consumer.html, or by email at cp.ins@state.or.us. Plan Sponsoes Discretionary Authority; Standard of Review The Plan Sponsor is the sole fiduciary of the plan, and exercises all discretionary authority and control over the administration of the plan and the management and disposition of plan assets. Benefits under the plan will be paid only if the Plan Sponsor decides, in its discretion, that the member or beneficiary is entitled to such benefits. Any construction of the terms of any plan document and any determination of fact adopted by the Plan Sponsor shall be final and legally binding on the parties. A court of law or arbitrator reviewing any fiduciary's decision, including one relating the plan interpretation or a benefit claim, must consider only the documents, testimony and other evidence that were presented to the fiduciary at the time the fiduciary made the decision. In addition, the court or arbitrator must use the 'arbitrary and capricious' standard of review. That is, the fiduciary's determination can be reversed only if it was made in bad faith, is not supported by substantial evidence or is erroneous as to a question of law. The Plan Sponsor may hire someone to perform claims processing and other specified services in relation to the plan. Any such contractor will not be a fiduciary of the plan and will not exercise any of the discretionary authority and responsibility granted to the Plan Sponsor, as described above. Coordination of Benefits Coordinating with Other Group Health Plans - When benefits are coordinated, one plan pays benefits first (the `primary coverage') and the other plan pays benefits second (the `secondary coverage'). When you and/or your dependents are covered under more than one group health plan, the combined benefits payable by this plan and all other group plans will not exceed 100% of the eligible expense incurred by the individual. The plan assuming primary payer status will determine benefits first without regard to benefits provided under any other group health plan. Note: If your primary and secondary coverage both include a deductible, you will be required to satisfy each of those deductibles before benefits will be paid. SPD 0714_City of Ashland V2 091614 67 There are two types of Coordination of Benefits -'True' Coordination of Benefits and Non-Duplicating Coordination of Benefits (also called Integration of Benefits.) See the Medical Benefit Summary to determine if your plan offers True Coordination of Benefits or Non-Duplicating/Integration of Benefits. For True Coordination of Benefits, the primary plan will pay benefits first, subject to any deductibles, co-payments and co-insurance. The remaining balance will be passed on to the secondary payer. When this plan is the secondary payer, the balance of eligible expenses will be applied as if it was a new claim under this plan. Deductibles, co-payments and co-insurance relevant to this plan will be subtracted from the amount before paying the remainder. For Non-Duplicating Coordination of Benefits/Integration of Benefits, the primary plan will pay benefits first, subject to any deductibles, co-payments and co-insurance. The remaining balance will be passed on to the secondary payer. When this plan is the secondary payer, it will reimburse the balance of remaining eligible expenses, not to exceed normal plan liability if this plan had been primary. This means that if the primary payer has already paid as much as or more than this plan would have paid had this plan been primary, there will be no additional payment made. This does not apply to City of Ashland. Government Programs and Other Group Health Plans The term group health plan, as it relates to coordination of benefits, includes the government programs Medicare, Medicaid and TriCare. The regulations governing these programs take precedence over the determination of benefits under this plan. For example, in determining the benefits payable under the plan, the plan will not take into account the fact that you or any eligible dependent(s) are eligible for or receive benefits under a Medicaid plan. The term group health plan also includes all group insurance and group subscriber contracts, such as union welfare plans. Order of Payment When Coordinating with Other Group Health Plans • If the other plan does not include `coordination of benefits,' that plan is primary and this plan is secondary. • If you are covered as an employee on one plan and a dependent on another, your Plan Sponsor's plan is primary. • When a child is covered under both parents' policies and the parents are either married or are living together (regardless of whether or not they have ever been married): - The parent whose birthday falls first in a benefit year has the primary plan; or - If both parents have the same birthday, the parent who has been covered the longest has the primary plan. • When a child is covered under both parents' plans and the parents are divorced, separated, or not living together (regardless of whether or not they have ever been married): If a court order specifies that one parent is responsible for the child's healthcare expenses, the mandated parent's coverage is primary regardless of custody. - If a court order specifies that both parents are responsible for the child's healthcare expenses, the parent whose birthday falls first in a benefit year has the primary plan. If both parents have the same birthday, the parent who has been covered the longest has the primary plan. If a court order specifies that both parents have joint custody without specifying that one parent has responsibility for the child's healthcare expenses, the parent whose birthday falls first in a benefit year has the primary plan. If both parents have the same birthday, the parent who has been covered the longest has the primary plan. - If there is no court order, the order of benefits for the child are as follows: o The custodial parent's coverage is primary; o The spouse of the custodial parent's coverage pays second; o The natural parent without custody's coverage pays third; and o The spouse of the natural parent without custody's coverage pays fourth. SPD 0714_City of Ashland V2 091614 68 • If a plan covers you as an active employee or a dependent of an active employee, that plan is primary. Another plan covering you as inactive, laid off, or retired is secondary. • When this plan covers you or your dependent pursuant to COBRA or under a right of continuation pursuant to other federal law, the plan covering you or your dependent as an employee, member, subscriber, or retiree or covering you or your dependent as a dependent of an employee, member, subscriber or retiree is the primary plan and this plan's coverage is the secondary plan. • If none of these rules apply, the coverage that has been in place longest is primary. Most insurers or administrators send you an explanation of benefits, or EOB, when they pay a claim. If your other plan's coverage is primary, send PacificSource the other plan's EOB with your original bill and they will process your claim. If you receive more than you should when your benefits are coordinated, you will be expected to repay any over-payment to the plan. Right to Make Payments to Other Organizations -Whenever payments, which should have been made by this plan, have been made by any other plan(s), this plan has the right to pay the other plan(s) any amount necessary to satisfy the terms of this coordination of benefits provision. Amounts paid will be considered benefits paid under this plan and, to the extent of such payments, the plan will be fully released from any liability regarding the person for whom payment was made. Automobile Insurance -This plan provides benefits relating to medical expenses incurred as a result of an automobile accident on a secondary basis only. Benefits payable under this plan will be coordinated with and secondary to benefits provided or required by any no-fault automobile insurance statute, whether or not a no-fault policy is in effect, and/or any other automobile insurance. Any benefits provided by this plan will be subject to the plan's reimbursement and/or subrogation provisions. OTHER IMPORTANT PLAN PROVISIONS Assignment of Benefits All benefits payable by the plan are automatically assigned to the provider of services or supplies, unless evidence of previous payment is submitted with the claim form. However, the plan reserves the right to reimburse the member, the provider, or both jointly. Payments made in accordance with an assignment are made in good faith and release the plan's obligation to the extent of the payment. Payments will also be made in accordance with any assignment of rights required by a state Medicaid plan. Members are expressly prohibited from assigning any right to payment of benefits under a Benefit Program, including this plan. No attempts at assignment of any such expenses under a Benefit Program will be recognized. Except as may be expressly prescribed in an agreement to which the Plan Sponsor is a party, nothing contained in any written designation of coverage under a Benefit Program will make the Benefit Program, or the Plan Sponsor or any other employer, liable to any third-party to whom a member may be liable for medical care, treatment or services. Proof of Loss The Plan Sponsor has the right to require a claimant to undergo physical or psychological examinations relating to the claimant's illness, injury or condition as often as the Plan Sponsor deems reasonably necessary while the claim for benefits is pending. The Plan Sponsor also has the right to require an autopsy in case of death (where not prohibited by law). No Verbal Modifications of Plan Provisions No verbal statement made by anyone involved in administering this plan can waive any of the terms or conditions of this plan or prevent the Plan Sponsorfrom enforcing any provision of this plan. Waivers are valid only if they are contained in a written instrument signed by an authorized individual on behalf of the Plan Sponsor. Any such written waiver will be valid only as to the specific plan, term or condition set forth in the written instrument. Unless specifically stated otherwise, a written waiver will be valid only for the specific claim involved at the time, and will not be a continuing waiver of the term or condition in the future. SPD 0714_City of Ashland V2 091614 69 Reimbursement to the Plan This section applies whenever another party (including your own insurer under an automobile or other policy) is legally responsible or agrees to compensate you or your dependent, by settlement, verdict or otherwise, for an illness or injury. In that case, you or your dependent (or the legal representatives, estate or heirs of either you or your dependent), must promptly reimburse the plan for any benefits it paid relating to that illness or injury, up to the full amount of the compensation received from the other party (regardless of how that compensation may be characterized and regardless of whether you or your dependent have been made whole). If the plan has not yet paid benefits relating to that illness or injury, the plan may reduce or deny future benefits on the basis of the compensation received by you or your dependent. Benefits relating to such illness or injury will not be payable by the plan until you sign and return a statement, provided by the plan, acknowledging your obligation to reimburse the plan under this provision. That obligation will arise upon the payment of any plan benefits relating to the illness or injury, whether or not you sign such a statement. You or your dependent must cooperate with the plan and its authorized representatives, and must sign and deliver such documents as the plan or its agents reasonably request to protect the plan's right of reimbursement. You or your dependent must also provide any relevant information and take such actions as the plan or its agents reasonably request to assist the plan in making a full recovery of the reasonable value of the benefits provided. You or your dependent must not take any action that prejudices the plan's right of reimbursement. In order to secure the rights of the plan under this section, you or your dependent hereby: (1) grant to the plan a first priority lien against the proceeds of any such settlement, verdict or other amounts received by you or your dependent; and (2) assign to the plan any benefits you or your dependent may have under any automobile policy or other coverage, to the extent of the plan's claim for reimbursement. The reimbursement required under this provision will not be reduced to reflect any costs or attorneys' fees incurred in obtaining compensation unless separately agreed to, in writing, by the Plan Sponsor, in the exercise of its sole discretion. This plan expressly disavows and repudiates the make whole doctrine, which, if applicable, would prevent the plan from receiving a recovery unless a member has been 'made whole' with regard to illness or injury that is the responsibility of a third party. This plan also expressly disavows and repudiates the common fund doctrine, which, if applicable, would require the plan to pay a portion of the attorney fees and costs expended in obtaining a recovery. These doctrines have no application to this plan, since the plan's recovery rights apply to the first dollars payable by a third party. Subrogation This section applies whenever another party (including your own insurer under an automobile or other policy) is legally responsible or agrees to compensate you or your dependent for you or your dependent's illness or injury and the plan has paid benefits related to that illness or injury. The plan is subrogated to all of the rights of you or your dependent against any party liable for you or your dependent's illness or injury to the extent of the reasonable value of the benefits provided to you or your dependent under the plan. The plan may assert this right independently of you or your dependent. You and your dependent are obligated to cooperate with the plan and its authorized representatives in order to protect the plan's subrogation rights. Cooperation means providing the plan or its agents with any relevant information requested by them, signing and delivering such documents as the plan or its agents reasonably request to secure the plan's subrogation claim, and obtaining the consent of the plan or its agents before releasing any party from liability for payment of medical expenses. If you or your dependent enters into litigation or settlement negotiations regarding the obligations of other parties, you or your dependent must not prejudice, in any way, the subrogation rights of the plan under this section. The costs of legal representation of the plan in matters related to subrogation will be borne solely by the plan. The costs of legal representation of you or your dependent must be borne solely by you or your dependent. SPD 0714_City of Ashland V2 091614 70 Recovery of Excess Payments Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this plan, or were made in error by the plan, the plan has the right to recover these payments from any individual (including yourself), insurance company or other organization to whom the payments were made or to withhold payment, if necessary, on future benefits until the overpayment is recovered. If excess or erroneous payments were made for services rendered to your dependent(s), the plan has the right to withhold payment on your future benefits until the overpayment is recovered. Further, whenever payments have been made based on fraudulent information provided by you, the plan will exercise all available legal rights, including its right to withhold payment on future benefits, until the overpayment is recovered. In the same manner, if the plan applies medical expenses to the plan deductible that would not otherwise be reimbursable under the terms of this policy; the plan may deduct a like amount from the accumulated deductible amounts and/or recover payment of medical expenses that would have otherwise been applied to the deductible. The fact that a medical expense was applied to the plan's deductible, or that a drug was provided under the plan's prescription drug program, does not in itself create an eligible expense or infer that benefits will continue to be provided for an otherwise excluded condition. Right To Receive and Release Necessary Information The plan may, without the consent of or notice to any person, release to or obtain from any organization or person, information needed to implement plan provisions, including medical information. When you request benefits, you must either furnish or authorize the release of all the information required to implement plan provisions. Your failure to fully cooperate will result in a denial of the requested benefits and the plan will have no further liability for such benefits. Under normal conditions, benefits are payable to the provider of services or supplies, unless evidence of previous payment is submitted with the claim form. If conditions exist under which a valid release or assignment cannot be obtained, the plan may make payment to any individual or organization that has assumed the care or principal support for you and is equitably entitled to payment. The plan must make payments to your separated/divorced spouse, state child support agencies or Medicaid agencies if required by a qualified medical child support order (QMCSO) or state Medicaid law. The plan may also honor benefit assignments made prior to your death in relation to remaining benefits payable by the plan. Any payment made by the plan in accordance with this provision will fully release the plan of its liability to you. Reliance on Documents and Information Information required by the Plan Sponsor or PacificSource may be provided in any form or document that the Plan Sponsor and PacificSource considers acceptable and reliable. The Plan Sponsor and PacificSource rely on the information provided by you and others when evaluating coverage and benefits under the plan. All such information, therefore, must be accurate, truthful and complete. The Plan Sponsor and PacificSource is entitled to conclusively rely upon, and will be protected for any action taken in good faith in relying upon, any information provided to the Plan Sponsor or PacificSource. In addition, any fraudulent statement, omission or concealment of facts, misrepresentation, or incorrect information may result in the denial of the claim, cancellation or rescission of coverage, or any other legal remedy available to the plan. No Waiver The failure of the Plan Sponsorto enforce strictly any term or provision of this plan will not be construed as a waiver of such term or provision. The Plan Sponsor reserves the right to enforce strictly any term or provision of this plan at any time. SPD 0714_City of Ashland V2 091614 71 Physician/Patient Relationship This plan is not intended to disturb the physician/patient relationship. Physicians, practitioners and other health care providers are not agents or delegates of the Plan Sponsor, or the Third Party Administrator. Nothing contained in this plan will require you or your dependent to commence or continue medical treatment by a particular provider. Further, nothing in this plan will limit or otherwise restrict a physician or practitioner's judgment with respect to the physician or practitioner's ultimate responsibility for patient care in the provision of medical services to you or your dependent. Plan not responsible for Quality of Health Care You and your enrolled dependents have the right to select your health care provider. Neither the plan, your Plan Sponsor, nor Third Party Administrator is responsible for the quality of care received and cannot be held liable for any claim or damages connected with injuries suffered while receiving health services or supplies. Plan is not a Contract of Employment Nothing contained in this plan will be construed as a contract or condition of employment between the Plan Sponsor and any employee. All employees are subject to discharge to the same extent as if this plan had never been adopted. Right to Amend or Terminate Plan Plan Sponsor reserves the right to amend, modify or terminate the plan in any manner, for any reason, at any time. If changes occur, your Plan Sponsorwill notify you of changes to your plan. If your health plan terminates and your Plan Sponsor does not replace the coverage with another group policy, your Plan Sponsor is required by law to advise you in writing of the termination. When this plan terminates, your Plan Sponsorwill notify you about any available options for you to continue your coverage. The Plan Sponsor may pay your medical claims if a workers' compensation claim has been denied on the basis that the illness or injury is not work related, and the denial is under appeal. But before PacificSource does that, you must sign a written agreement to reimburse the Plan Sponsor any money you recover from the workers' compensation coverage. Rescissions The Plan Sponsor or PacificSource may not rescind the coverage of a member unless the member, or person seeking coverage on behalf of the member, performs an act, practice or omission that constitutes fraud or makes an intentional misrepresentation of a material fact as prohibited by the terms of this plan and the Plan Sponsor or PacificSource gives the member a 30-day prior written notice. PacificSource may not rescind the policyholder's group health benefit plan unless the policyholder, or representative of the policyholder, performs an act, practice or omission that constitutes fraud or makes an intentional misrepresentation of a material fact as prohibited by the terms of this plan and PacificSource gives a 30-day prior written notice to all member covered under the plan. Rescissions do not include a cancellation or discontinuance of coverage that is prospective or to the extent it is attributable to a failure to timely pay required contributions towards the cost of coverage. Applicable Law This is a self-insured benefit plan. As such, Federal law preempts State law and jurisdiction. To the extent not preempted by federal law, the laws of the state of Oregon shall apply. PRIVACY AND CONFIDENTIALITY This notice is intended to bring the City of Ashland Employee Benefit Plan into compliance with the requirements of Section 164.504(f) of the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, 45 C.F.R. parts 160 through 164 (the `HIPAA Privacy Rule') by establishing the conditions under which the Plan Sponsor will receive, use and/or disclose protected health information. SPD 0714_City of Ashland V2 091614 72 Permitted Disclosures of Protected Health Information to the Plan Sponsor Subject to the conditions of the 'No Disclosure of Protected Health Information to the Employer Without Certification by Employer' and 'Conditions of Disclosure of Protected Health Information to the Employer', the plan (and any third party administrator or business associate acting on behalf of the plan) may disclose individuals' protected health information to the Plan Sponsorfor the Plan Sponsoror PacificSource to carry out plan administration functions. The plan (and any third party administrator or business associate acting on behalf of the plan) may not disclose individuals' protected health information to the Plan Sponsor for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor. No Disclosure of Protected Health Information to the Plan Sponsorwithout Certification by Plan Sponsor Except as provided below in 'Disclosures of Summary Health Information and Enroll ment/Disenrollment Information to the Employer,' with respect to the plan's disclosure of summary health information and enrol lment/disenrollment information, the plan will not disclose protected health information to any employee of the Plan Sponsor. Conditions of Disclosure of Protected Health Information to the Plan Sponsor The Plan Sponsor certifies that the plan has been amended to incorporate this section and agrees to the following restrictions and conditions of receiving protected health information (other than summary health information or enrollment/disenrollment information as explained in 'Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the Plan Sponsor below). The Plan Sponsor shal I: • Not use or further disclose the protected health information other than as permitted or required herein or as required by law. • Ensure that any agent(s), including a subcontractor, to whom it provides protected health information received from the plan, agrees to the same restrictions and conditions that apply to the Plan Sponsor with respect to such protected health information. • Not use or disclose protected health information for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor. • Report to the plan any use or disclosure of protected health information that is inconsistent with the uses or disclosures provided for of which the Plan Sponsor becomes aware. • Make available protected health information to comply with an individual's right to access protected health information in accordance with 45 C.F.R. Section 164.524. • Make available protected health information for amendment and incorporate any amendments to protected health information in accordance with 45 C.F.R. Section 164.526. • Make available the information required to provide an accounting of disclosures in accordance with 45 C.F.R. §164.528. • Make its internal practices, books and records relating to the use and disclosure of protected health information received from the plan available to the Secretary of the Department of Health and Human Services for purposes of determining compliance by the plan with the HIPAA Privacy Rule. • If feasible, return or destroy all protected health information received from the plan that the Plan Sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, the Plan Sponsorwill limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible. • Ensure that the required adequate separation, described in 'Required Separation Between the Plan and the Plan Sponsor below, is established and maintained. Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the Plan Sponsor • The plan (or a third party administrator of the plan) may disclose summary health information to the Plan Sponsor without the need to comply with the conditions and restrictions of 'No Disclosure of Protected Health Information to the Plan Sponsor Without Certification by Plan Sponsor and SPD 0714_City of Ashland V2 091614 73 'Conditions of Disclosure of Protected Health Information to the Plan Sponsor, if the Plan Sponsor requests the summary health information for the purpose of: - Obtaining premium bids from health plans (including health insurance issuers) for providing health insurance coverage under the plan; or - Modifying, amending, or terminating the plan • The plan (or a third party administrator of the plan) may disclose information on whether the individual is participating in the group health plan, or is enrolled in or has disenrolled from the plan without the need to comply with the conditions and restrictions of 'No Disclosure of Protected Health Information to the Plan Sponsor Without Certification by Plan Sponsor and 'Conditions of Disclosure of Protected Health Information to the Plan Sponsor' Required Separation between the Plan and the Plan Sponsor • The following classes of employees or other persons under the control of the Plan Sponsorwill have access to protected health information received from the plan (or from a health insurance issuer with respect to the plan): - Human Resources • No other persons shall have access to protected health information. The listed classes of employees or other persons under the control of the Plan Sponsor will have access to protected health information solely to perform the plan administration functions that the Plan Sponsor performs for the plan. They will be subject to disciplinary action and/or sanctions (including termination of employment or affiliation with the Plan Sponsor) for any use or disclosure of protected health information in violation of the provisions of this plan. DEFINITIONS Wherever used in this plan, the following definitions apply to the terms listed below, and the masculine includes the feminine and the singular includes the plural. For the purpose of this plan, 'employee' includes the Plan Sponsorwhen covered by this plan. Other terms are defined where they are first used in the text. Abutment is a tooth used to support a prosthetic device (bridges, partials or overdentures). With an implant, an abutment is a device placed on the implant that supports the implant crown. Accident means an unforeseen or unexpected event causing injury that requires medical attention. Actively at work or active employment means that an employee is performing in the customary manner all of the regular duties of his/her occupation with the Plan Sponsor, either at one of the Plan Sponsor's regular places of business or at some location to which the Plan Sponsor's business requires the employee to travel to perform his/her regular duties assigned by the Plan Sponsor. An employee is also considered to be actively at work on each day of a regular paid vacation or non-work day, but only if the employee is performing in the customary manner all of the regular duties of the employee's occupation with the Plan Sponsor on the immediately preceding regularly scheduled workday. Advanced diagnostic imaging means diagnostic examinations using CT scans, MRIs, PET scans, CATH labs, and nuclear cardiology studies. Adverse benefit determination means a denial, reduction, or termination of a healthcare item or service, or a failure or refusal to provide or to make a payment in whole or in part for a healthcare item or service, that is based on the Plan Sponsor's or PacificSource's: • Denial of eligibility for or termination of enrollment in a health benefit plan; • Rescission or cancellation of a policy or coverage; • Imposition of a source-of-injury exclusion, network exclusion, annual benefit limit or other limitation on otherwise covered items or services; • Determination that a healthcare item or service is experimental, investigational, or not medically necessary, effective, or appropriate; or • Determination that a course or plan of treatment that a member is undergoing it an active course of treatment for purposes of continuity of care under ORS 743.854. Advantage Essential Network is the exclusive provider network that provides dental care to members under this plan. SPD 0714_City of Ashland V2 091614 74 Allowable fee is the dollar amount established by the plan for reimbursement of charges for specific services or supplies provided by nonparticipating providers. The plan uses several sources to determine the allowable amount. Depending on the service or supply and the geographical area in which it is provided, the allowable amount may be based on data collected from the Centers for Medicare and Medicaid Services (CMS), Viant Health Payment Solutions, other nationally recognized databases, or PacificSource. Where the provider network is deemed adequate, the allowable fee for professional services is based on PacificSource's standard participating provider reimbursement rate or a contracted reimbursement rate. Outside the PacificSource service area and in areas where the participating provider network is not deemed adequate, the allowable fee is based on the usual, customary, and reasonable charge (UCR) at the 85th percentile. UCR is based on data collected for a geographic area. Provider charges for each type of service are collected and ranked from lowest to highest. Charges at the 85th position in the ranking are considered to be the 85th percentile. Alveolectomy is the removal of bone from the socket of a tooth. Amalgam is a silver-colored material used in restoring teeth. Ambulatory surgical center means a facility licensed by the appropriate state or federal agency to perform surgical procedures on an outpatient basis. Ancillary Services means service rendered in connection with Inpatient or Outpatient care in a Hospital or in connection with a medical emergency, such as assistant surgeon, anesthesiology, ambulance, pathology and radiology. Approved clinical trials are Phase I, II, III, or IV clinical trials for the prevention, detection, or treatment of cancer or another life-threatening condition or disease. Authorized representative is an individual who by law or by the contest of a person may act on behalf of the person. Benefit year means the 12-month period beginning on each January 1 and ending on the next December 31. Cardiac rehabilitation refers to a comprehensive program that generally involves medical evaluation, prescribed exercise, and cardiac risk factor modification. Education, counseling, and behavioral interventions are sometimes used as well. Phase I refers to inpatient services that typically occur during hospitalization for heart attack or heart surgery. Phase II refers to a short-term outpatient program, usually involving ECG-monitored exercise. Phase III refers to a long-term program, usually at home or in a community-based facility, with little or no ECG monitoring. Cast restoration includes crowns, inlays, onlays, and other restorations made to fit a patient's tooth that are made at a laboratory and cemented onto the tooth. Certificate of Creditable Coverage means a certificate or other documentation that shows previous health insurance coverage for a member and can be used to reduce the length of any pre-existing condition exclusions under a plan. See Creditable coverage. Chemical dependency means the addictive relationship with any drug or alcohol characterized by either a physical or psychological relationship, or both, that interferes with the individual's social, psychological, or physical adjustment to common problems on a recurring basis. Chemical dependency does not include addiction to, or dependency on, tobacco products or foods. Claims Administrator means the organization selected by the City of Ashland to provide claims processing and adjudication under their plans. The Claims Administrator for their medical, vision and pharmacy coverage is PacificSource. Composite resin is a tooth-colored material used in restoring teeth. Contracted amount means the amount that participating providers have contracted to accept as payment in full for covered expenses under the plan. Co-payment or co-insurance is the out-of-pocket amount a member is required to pay to a provider. Creditable coverage means a member's prior health coverage that meets the following criteria: • There was no more than a 63-day break between the last day of coverage under the previous policy and the first day of coverage under this policy. The 63-day limit excludes the Plan Sponsor's eligibility waiting period. • The prior coverage was one of the following types of insurance: group coverage (including Federal Employee Health Benefit Plans and Peace Corps), individual coverage (including student health SPD 0714_City of Ashland V2 091614 75 plans), Medicaid, Medicare, TRICARE, Indian Health Service or tribal organization coverage, state high-risk pool coverage, and public health plans. Curettage is the scraping and cleaning of the walls of a real or potential space, such as a gingival pocket or bone, to remove pathological material. Custodial Care means non-medical care that is primarily to assist with activities of daily living, whether or not the care is administered by a licensed provider. Deductible means the portion of the healthcare expense that must be paid by the member before the benefits of this plan are applied. Dental emergency means the sudden and unexpected onset of a condition, or exacerbation of an existing condition, requiring necessary care to control pain, swelling or bleeding in or around the teeth and gums. Such emergency care must be provided within 48 hours following the onset of the emergency and includes treatment for acute infection, pain, swelling, bleeding, or injury to natural teeth and oral structures. The emergency care does not include follow-up care such as, but not limited to, crowns, root canal therapy, or prosthetic benefits. Dentist means a person acting within the scope of their license, holding the degree of Doctor of Medicine (M.D.), Doctor of Dental Surgery (D.D.S.), or Doctor of Dental Medicine (D.M.D.), and who is legally entitled to practice dentistry in all its branches under the laws of the state or jurisdiction where the services are rendered. Durable medical equipment means equipment that can withstand repeated use; is primarily and customarily used to serve a medical purpose rather than convenience or comfort; is generally not useful to a person in the absence of an illness or injury; is appropriate for use in the home; and is prescribed by a physician. Examples of durable medical equipment include but are not limited to hospital beds, wheelchairs, crutches, canes, walkers, nebulizers, commodes, suction machines, traction equipment, respirators, TENS units, and hearing aids. Durable medical equipment supplier means a PacificSource contracted provider or a provider that satisfies the criteria in the Medicare Qualify Standards for Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description. Elective surgery or procedure refers to a surgery or procedure for a condition that does not require immediate attention and for which a delay would not have a substantial likelihood of adversely affecting the health of the patient. Eligible dental provider means a physician, dentist, oral surgeon, endodontist, orthodontist, periodontist, or pedodontist. Eligible provider may also include a denturist or dental hygienist to the extent that he/she operates within the scope of their license. Emergency medical condition means a medical condition: • That manifests itself by acute symptoms of sufficient severity, including severe pain that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would: - Place the health of a person, or an unborn child in the case of a pregnant woman, in serious jeopardy; Result in serious impairment to bodily functions; or Result in serious dysfunction of any bodily organ or part; or • With respect to a pregnant woman who is having contractions, for which there is inadequate time to affect a safe transfer to another hospital before delivery or for which a transfer may pose a threat to the health or safety of the woman or the unborn child. Emergency medical screening exam means the medical history, examination, ancillary tests, and medical determinations required to ascertain the nature and extent of an emergency medical condition. Emergency services means, with respect to an emergency medical condition: • An emergency medical screening exam that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and • Such further medical examination and treatment as are required under 42 U.S.C. 1395dd to stabilize the patient to the extent the examination and treatment are within the capability of the staff and facilities available at a hospital. Employee means any individual employed by a Plan Sponsor. SPD 0714_City of Ashland V2 091614 76 Endorsement is a written attachment that alters and supersedes any of the terms or conditions set forth in this contract. Enrollee means an employee, dependent of the employee, or individual otherwise eligible and enrolled for coverage under this plan. In this policy, enrollee is referred to as subscriber or member. Essential health benefits are services defined as such by the Secretary of the U.S. Department of Health and Human Services. Essential health benefits fall into the following categories: • Ambulatory patient services; • Emergency services; • Hospitalization; • Maternity and newborn care; • Mental health and substance use disorder services, including behavioral health treatment; • Prescription drugs; • Rehabilitative and habilitative services and devices; • Laboratory services; • Preventive and wellness services and chronic disease management; and • Pediatric services, including oral and vision care. Exclusion period means a period during which specified conditions, treatments or services are excluded from coverage. Experimental or investigational procedures means services, supplies, protocols, procedures, devices, chemotherapy, drugs or medicines, or the use thereof, that are experimental or investigational for the diagnosis and treatment of illness or injury. • Experimental or investigational services and supplies include, but are not limited to, services, supplies, procedures, devices, chemotherapy, drugs or medicines, or the use thereof, which at the time they are rendered and for the purpose and in the manner they are being used: - Have not yet received full U.S. government agency required approval (e.g., FDA) for other than experimental, investigational, or clinical testing; - Are not of generally accepted medical practice in the state of Oregon or as determined by PacificSource in consultation with medical advisors, medical associations, and/or technology resources; - Are not approved for reimbursement by the Centers for Medicare and Medicaid Services; Are furnished in connection with medical or other research; or Are considered by any governmental agency or subdivision to be experimental or investigational, not considered reasonable and necessary, or any similar finding. • When making decisions about whether treatments are investigational or experimental, PacificSource relies on the above resources as well as: Expert opinions of specialists and other medical authorities; - Published articles in peer-reviewed medical literature; External agencies whose role is the evaluation of new technologies and drugs; and - External review by an independent review organization. • The following will be considered in making the determination whether the service is in an experimental and/or investigational status: - Whether there is sufficient evidence to permit conclusions concerning the effect of the services on health outcomes; Whether the scientific evidence demonstrates that the services improve health outcomes as much or more than established alternatives; - Whether the scientific evidence demonstrates that the services' beneficial effects outweigh any harmful effects; and - Whether any improved health outcomes from the services are attainable outside an investigational setting. SPD 0714_City of Ashland V2 091614 77 Formulary is a list of approved brand name medications used to treat various medical conditions. The formulary list is developed by the pharmacy benefits management company and PacificSource. Generic drugs are drugs that, under federal law, require a prescription by a licensed physician (M.D. or D.O.) or other licensed medical provider and are not a brand name medication. By law, generic drugs must have the same active ingredients as the brand name medication and are subject to the same standards of their brand name counterpart. Grievance means: • A request submitted by a member or an authorized representative of a member; In writing, for an internal appeal or an external review; or - In writing or orally, for an expedited internal review or an expedited external review; or • A written complaint submitted by a member or an authorized representative of a member regarding: The availability, delivery, or quality of a healthcare service; Claims payment, handling, or reimbursement for healthcare services and, unless the member has not submitted a request for an internal appeal, the complaint is not disputing an adverse benefit determination; or Matters pertaining to the contractual relationship between a member and PacificSource. Health care provider means a physician, practitioner, nurse, hospital or specialized treatment facility as defined in this document. Health benefit plan means any hospital expense, medical expense, or hospital or medical expense policy or certificate, healthcare contractor or health maintenance organization subscriber contract, or any plan provided by a multiple employer welfare arrangement or by another benefit arrangement defined in the federal Employee Retirement Income Security Act of 1974, as amended, to the extent that plan is subject to state regulation. Hearing aids mean any non-disposable, wearable instrument or device designed to aid or compensate for impaired human hearing and any necessary ear mold, part, attachments or accessory for the instrument or device, except batteries and cords. Hearing aids include any amplifying device that does not produce as its output an electrical signal that directly stimulates the auditory nerve. For the purpose of this definition, such amplifying devices include air conduction and bone conduction devices, as well as those that provide vibratory input to the middle ear. Homebound means the ability to leave home only with great difficulty with absences infrequently and of short duration. Infants and toddlers will not be considered homebound without medical documentation that clearly establishes the need for home skilled care. Lack of transportation is not considered sufficient medical criterion for establishing that a person is homebound. Hospital means an institution licensed as a 'general hospital' or 'intermediate general hospital' by the appropriate state agency in the state in which it is located. Illness includes a physical or mental condition that results in a covered expense. Physical illness is a disease or bodily disorder. Mental illness is a psychological disorder that results in pain or distress and substantial impairment of basic or normal functioning. Incurred expense means charges of a healthcare provider for services or supplies for which a member becomes obligated to pay. The expense of a service is incurred on the day the service is rendered, and the expense of a supply is incurred on the day the supply is delivered. Initial enrollment period means a period of 60 days following the date an individual is first eligible to enroll. Injury means bodily trauma or damage that is independent of disease or infirmity. The damage must be caused solely by external and accidental means and does not include muscular strain sustained while performing a physical activity. Inquiry means a written request for information or clarification about any subject matter related to the member's health benefit plan. Internal appeal means a review by PacificSource or your Plan Sponsor of an adverse benefit determination made by PacificSource, Leave of absence is a period of time off work granted to an employee by the Plan Sponsor at the employee's request and during which the employee is still considered to be employed and is carried on the employment records of the Plan Sponsor. A leave can be granted for any reason acceptable to the Plan Sponsor, including disability and pregnancy. SPD 0714_City of Ashland V2 091614 78 Lifetime means the period of time a member is enrolled in this plan or any other Plan Sponsored by the Plan Sponsor. Mastectomy is the surgical removal of all or part of a breast or a breast tumor suspected to be malignant. Medically necessary means those services and supplies that are required for diagnosis or treatment of illness or injury and that are: • Consistent with the symptoms or diagnosis and treatment of the condition; • Consistent with generally accepted standards of good medical practice in the state of Oregon, or expert consensus physician opinion published in peer-reviewed medical literature, or the results of clinical outcome trials published in peer-reviewed medical literature; • As likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any other service or supply, both as to the disease or injury involved and the patient's overall health condition; • Not for the convenience of the member or a provider of services or supplies; • The least costly of the alternative services or supplies that can be safely provided. When specifically applied to a hospital inpatient, it further means that the services or supplies cannot be safely provided in other than a hospital inpatient setting without adversely affecting the patient's condition or the quality of medical care rendered. Services and supplies intended to diagnose or screen for a medical condition in the absence of signs or symptoms, or of abnormalities on prior testing, including exposure to infectious or toxic materials or family history of genetic disease, are not considered medically necessary under this definition (see General Exclusions - Screening tests). Medical supplies means items of a disposable nature that may be essential to effectively carry out the care a physician has ordered for the treatment or diagnosis of an illness or injury. Examples of medical supplies include but are not limited to syringes and needles, splints and slings, ostomy supplies, sterile dressings, elastic stockings, enteral foods, drugs or biologicals that must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment or to assure the proper functioning of this equipment (e.g. Albuterol for use in a nebulizer). Member means an individual insured through the Plan Sponsor. Mental and/or chemical healthcare facility means a corporate or governmental entity or other provider of services for the care and treatment of chemical dependency and/or mental or nervous conditions which is licensed or accredited by the Joint Commission on Accreditation of Hospitals or the Commission on Accreditation of Rehabilitation Facilities for the level of care which the facility provides. Mental and/or chemical healthcare program means a particular type or level of service that is organizationally distinct within a mental and/or chemical healthcare facility. Mental and/or chemical healthcare provider means a person that has met the credentialing requirements of PacificSource, is otherwise eligible to receive reimbursement under the policy and is: • A healthcare facility where appropriately licensed or accredited by the Commission on Accreditation of Hospitals or the Commission on Accreditation of Rehabilitation Facilities; • A residential program or facility; • A day or partial hospitalization program; • An outpatient service; or • An individual behavioral health or medical professional authorized for reimbursement under Oregon law. Mental or nervous conditions means all disorders listed in the `Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, Fourth Edition' except for: • Mental Retardation (diagnostic codes 317, 318.0, 318.1, 318.2, 319); • Learning Disorders (diagnostic codes 315.00, 315.1, 315.2, 315.9); • Paraphilias (diagnostic codes 302.4, 302.81, 302.89, 302.2, 302.83, 302.84, 302.82, 302.9); and • Gender Identity Disorders in Adults (diagnostic codes 302.85, 302.6, 302.9 - this exception does not extend to children and adolescents 18 years of age or younger); and SPD 0714_City of Ashland V2 091614 79 • V codes (diagnostic codes V15.81 through V71.09 - this exception does not extend to children five years of age or younger for diagnostic codes V61.20, V61.21, and V62.82). Network not available means a member does not have reasonable geographic access to a PacificSource participating provider for a medical service or supply. Non-participating provider is a provider of covered medical services or supplies that does not directly or indirectly hold a provider contract or agreement with PacificSource. Non-preferred drugs are covered brand name medications not on the Preferred Drug List. Orthotic devices means rigid or semirigid devices supporting a weak or deformed leg, foot, arm, hand, back or neck or restricting or eliminating motion in a diseased or injured leg, foot, arm, hand, back or neck. Benefits for orthotic devices include orthopedic appliances or apparatus used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body. An orthotic device differs from a prosthetic in that, rather than replacing a body part, it supports and/or rehabilitates existing body parts. Orthotic devices are usually customized for an individual's use and are not appropriate for anyone else. Examples of orthotic devices include but are not limited to Ankle Foot Orthosis (AFO), Knee Ankle Foot Orthosis (KAFO), Lumbosacral Orthosis (LSO), and foot orthotics. PacificSource refers to PacificSource Health Plans. PacificSource is the claims administrator of the Plan Sponsor's medical, vision and pharmacy coverage. References to PacificSource as paying claims or issuing benefits means that PacificSource processes a claim in accordance with the provisions of the Plan Sponsors plans. Participating provider means a physician, healthcare professional, hospital, medical facility, or supplier of medical supplies that directly or indirectly holds a provider contract or agreement with the plan. Periapical x-ray is an x-ray of the area encompassing or surrounding the tip of the root of a tooth. Periodontal maintenance is a periodontal procedure for patients who have previously been treated for periodontal disease. In addition to cleaning the visible surfaces of the teeth (as in prophylaxis) surfaces below the gum-line are also cleaned. This is a more comprehensive service than a regular cleaning (prophylaxis). Periodontal scaling and root planing means the removal of plaque and calculus deposits from the root surface under the gum line. Physical/occupational therapy is comprised of the services provided by (or under the direction and supervision of) a licensed physical or occupational therapist. Physical/occupational therapy includes emphasis on examination, evaluation, and intervention to alleviate impairment and functional limitation and to prevent further impairment or disability. Physician means a state-licensed Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.). Physician assistant is a person who is licensed by an appropriate state agency as a physician assistant. Plan means the City of Ashland Employee Benefits Plan, and all documents, including any contracts, administrative service agreements, Summary Plan Descriptions and any related terms and conditions associated with the Plan. Plan Administrator means the Risk Services Division of the City of Ashland, which has responsibility for the management of the plan. Plan Sponsor ('the Plan Sponsor' or `your Plan Sponsor'), means the City of Ashland. The City of Ashland is the fiduciary of the plan, and exercises all discretionary authority and control over the administration of the plan and the management and disposition of plan assets. The Plan Sponsorshall have the sole discretionary authority to determine eligibility for plan benefits or to construe the terms of the plan, and benefits under the plan will be paid only if the Plan Sponsor decides, in its discretion, that the member or beneficiary is entitled to such benefits. The Plan Sponsor has the right to amend, modify, or terminate the plan in any manner, at any time, regardless of the health status of any plan member or beneficiary. Practitioner means Doctor or Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Dental Medicine (D.M.D.), Doctor of Podiatry Medicine (D.P.M.), Doctor of Chiropractic (D.C.), Doctor of Optometry (O.D.), Licensed Nurse Practitioner (including Certified Nurse Midwife (C.N.M.) and Certified Registered Nurse Anesthetist (C.R.N.A.)), Registered Physical Therapist (R.P.T.), Speech Therapist, Occupational Therapist, Psychologist (Ph.D.), Licensed Clinical Social Worker (L.C.S.W.), Licensed Professional Counselor (L.P.C.), Licensed Marriage and Family Therapist SPD 0714_City of Ashland V2 091614 80 (LMFT), Licensed Psychologist Associate (LPA), Physician Assistant (PA), Audiologist, Acupuncturist, Naturopathic Physician, and Licensed Massage Therapist. Pre-existing condition means a condition (physical or mental) for which medical advice, diagnosis, care, or treatment was recommended by or received from a licensed provider within the six-month period ending on the enrollment date. For the purpose of this definition, the enrollment date of a member is the earlier of the effective date of coverage or the first day of any required group eligibility waiting period, and the enrollment date of a late enrollee is the effective date of coverage. Pregnancy does not constitute a pre-existing condition, nor does genetic information without a diagnosis of a condition related to such information. Preferred is a list of approved brand name medications used to treat various medical conditions. The Preferred Drug List is developed by the pharmacy benefits management company and PacificSource. Prescription drugs are drugs that, under federal law, require a prescription by a licensed physician (M.D. or D.O.) or other licensed medical provider. Prophylaxis is a cleaning and polishing of all teeth. Prosthetic devices (excluding dental) means artificial limb devices or appliances designed to replace in whole or in part an arm or a leg. Benefits for prosthetic devices include coverage of devices that replace all or part of an internal or external body organ, or replace all or part of the function of a permanently inoperative or malfunctioning internal or external organ, and are furnished on a physician's order. Examples of prosthetic devices include but are not limited to artificial limbs, cardiac pacemakers, prosthetic lenses, breast prosthesis (including mastectomy bras), and maxillofacial devices. Pulpotomy is the removal of a portion of the pulp, including the diseased aspect, with the intent of maintaining the vitality of the remaining pulpal tissue by means of a therapeutic dressing. Qualified domestic partner means a registered domestic partner or unregistered same gender domestic partner with an Affidavit of Domestic Partnership, supplied by the Plan Sponsor. Restoration is the treatment that repairs a broken or decayed tooth. Restorations include, but are not limited to, fillings and crowns. Routine costs of care means medically necessary conventional care, items, or services covered by the health benefit plan if typically provided absent a clinical trial. Routine costs of care do not include: • The drug, device, or service being tested in the clinical trial unless the drug, device, or service would be covered for that indication by the policy if provided outside of a clinical trial; • Items or services required solely for the provisions of the drug, device, or service being tested in the clinical trial; • Items or services required solely for the clinically appropriate monitoring of the drug, device, or service being tested in the clinical trial; • Items of services required solely for the prevention, diagnosis, or treatment of complications arising from the provision of the drug, device, or service being tested in the clinical trial; • Items or services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient; • Items or services customarily provided by a clinical trial sponsor free of charge to any participant in the clinical trial; or • Items or services that are not covered by the policy if provided outside of the clinical trial. Seasonal employee is an employee who is hired with the agreement that their employment will end after a predetermined period of time. Skilled nursing facility convalescent home means an institution that provides skilled nursing care under the supervision of a physician, provides 24-hour nursing service by or under the supervision of a registered nurse (R.N.), and maintains a daily record of each patient. Skilled nursing facilities must be licensed by an appropriate state agency and approved for payment of Medicare benefits to be eligible for reimbursement. Specialized treatment facility means a facility that provides specialized short-term or long-term care. The term specialized treatment facility includes ambulatory surgical centers, birthing centers, chemical dependency/substance abuse day treatment facilities, hospice facilities, inpatient rehabilitation facilities, mental and/or chemical healthcare facilities, organ transplant facilities, psychiatric day treatment facilities, residential treatment facilities, skilled nursing facilities, substance abuse treatment facilities, and urgent care treatment facilities. SPD 0714_City of Ashland V2 091614 81 Specialty drugs are high dollar oral, injectable, infused or inhaled biotech medications prescribed for the treatment of chronic and/or genetic disorders with complex care issues that have to be managed. The major conditions these drugs treat include but are not limited to: cancer, HIV/AIDS, hemophilia, hepatitis C, multiple sclerosis, Crohn's disease, rheumatoid arthritis, and growth hormone deficiency. Specialty pharmacies specialize in the distribution of specialty drugs and providing pharmacy care management services designed to assist patients in effectively managing their condition. Stabilize means to provide medical treatment as necessary to ensure that, within reasonable medical probability, no material deterioration of an emergency medical condition is likely to occur during or to result from the transfer of the patient from a facility; and with respect to a pregnant woman who is in active labor, to perform the delivery, including the delivery of the placenta. Subscriber means an employee or former employee insured under the Plan Sponsor's health policy through PacificSource. When a family unit that does not include an employee or former employee is insured under a policy, the oldest family member is referred to as the subscriber. Surgical procedure means any of the following operative procedures: • Procedures accomplished by cutting or incision • Suturing of wounds • Treatment of fractures, dislocations, and burns • Manipulations under general anesthesia • Visual examination of the hollow organs of the body including biopsy, or removal of tumors or foreign body • Procedures accomplished by the use of cannulas, needling, or endoscopic instruments • Destruction of tissue by thermal, chemical, electrical, laser, or ultrasound Telemedical means medical services delivered through a two-way video communication that allows a provider to interact with a patient who is at a different physical location than the provider. Temporomandibular Joint Disorder (TMJ) means any dysfunction or disorder of the jaw joint resulting in pain and impairment of the jaw. Third Party Administrator is an administrator hired by the Plan Sponsor to perform claims processing and other specified administrative services in relation to the plan. The third party administrator is not an insurer of health benefits under this plan, is not a fiduciary of the plan, and does not exercise any of the discretionary authority and responsibility granted to the Plan Sponsor. The third party administrator is not responsible for plan financing and does not guarantee the availability of benefits under this plan. The third party administrator is PacificSource Health Plans Tobacco use cessation program means a program recommended by a physician that follows the United States Public Health Services guidelines for tobacco use cessation. Tobacco use cessation program includes education and medical treatment components designed to assist a person in ceasing the use of tobacco products. Unregistered domestic partner means an individual of the same-gender who is joined in a domestic partnership with the subscriber and meets the following criteria: • Is at least 18 years of age; • Not related to the policyholder by blood closer than would bar marriage in Oregon or the state where they have permanent residence and are domiciled; • Shares jointly the same permanent residence with the policyholder for at least six months immediately preceding the date of application to enroll and intent to continue to do so indefinitely; • Has joint financial accounts with the policyholder and has agreed to be jointly responsible with the policyholder for each other's common welfare, including basic living expenses; • Has an exclusive domestic partnership with the policyholder and has no other domestic partner; • Does not have a legally binding marriage nor has had another domestic partner within the previous six months; • Was mentally competent to consent to contract when the domestic partnership began and remains mentally competent. Urgent care treatment facility means a healthcare facility whose primary purpose is the provision of immediate, short-term medical care for minor, but urgent, medical conditions. SPD 0714_City of Ashland V2 091614 82 Waiting period means the period of time before coverage becomes effective for a memberwho is otherwise eligible to enroll in the plan. Women's healthcare provider means an obstetrician, gynecologist, physician assistant or nurse practitioner specializing in women's health, or certified nurse midwife practicing within the applicable scope of practice. RIGHTS OF PLAN MEMBERS MEDICAID AND CHIP STATE CONTACT INFORMATION If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your Plan Sponsor, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health coverage through their Plan Sponsor. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for a Plan Sponsor-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your Plan Sponsor plan, your Plan Sponsor must permit you to enroll in your Plan Sponsor plan if you are not already enrolled. This is called a'special enrollment' opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your Plan Sponsor plan, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA (3272). If you live in one of the following States, you may be eligible for assistance paying your Plan Sponsor health plan premiums. The following list of States is current as of July 31, 2012. You should contact your State for further information on eligibility - ALABAMA - Medicaid COLORADO - Medicaid Website: http://www.medicaid.alabama.gov Medicaid Website: http://www.colorado.gov/ Phone: 1-855-692-5447 Medicaid Phone (In state): 1-800-866-3513 ALASKA - Medicaid _ Medicaid Phone (Out of state): 1-800-221-3943 Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 _ ARIZONA - CHIP FLORIDA - Medicaid Website: http://www.azahcccs.gov/applicants Website: https://www.flmedicaidtpirecovery.com/ Phone (Outside of Maricopa County): 1-877-764-5437 Phone: 1-877-357-3268 Phone (Maricopa County): 602-417-5437 GEORGIA - Medicaid Website: http://dch.georgia.gov/ Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150 IDAHO - Medicaid and CHIP MONTANA - Medicaid Medicaid Website: Website: www.accesstohealthinsurance.idaho.gov http://medicaidprovider.hhs.mt.gov/clientpages/ Medicaid Phone: 1-800-926-2588 clientindex.shtml CHIP Website: www.medicaid.idaho.gov Phone: 1-800-694-3084 CHIP Phone: 1-800-926-2588 INDIANA - Medicaid NEBRASKA -Medicaid Website: http://www.in.gov/fssa Website: www.ACCESSNebraska.ne.gov Phone: 1-800-889-9949 Phone: 1-800-383-4278 SPD 0714_City of Ashland V2 091614 83 IOWA - Medicaid NEVADA - Medicaid Website: www.dhs.state.ia.us/hipp/ Medicaid Website: http://dwss.nv.gov/ Phone: 1-888-346-9562 Medicaid Phone: 1-800-992-0900 KANSAS - Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884 KENTUCKY - Medicaid NEW HAMPSHIRE - Medicaid Website: http://chfs.ky.gov/dms/default.htm Website: Phone: 1-800-635-2570 http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 LOUISIANA - Medicaid NEW JERSEY - Medicaid and CHIP Website: http://www.lahipp.dhh.louisiana.gov Medicaid Website: -Phone: 1-888-695-2447 http://www.state.nj.us/humanservices/ MAINE - Medicaid dmahs/clients/medicaid/ Website: http://www.maine.gov/dhhs/ofi/public- Medicaid Phone: 1-800-356-1561 assistance/index.html CHIP Website: Phone: 1-800-977-6740 http://www.njfamilycare.org/index.html TTY 1-800-977-6741 CHIP Phone: 1-800-701-0710 MASSACHUSETTS - Medicaid and CHIP NEW YORK -Medicaid Website: http://www.mass.gov/MassHealth Website: Phone: 1-800-462-1120 http://www.nyhealth.gov/health-care/medicaid/ Phone: 1-800-541-2831 MINNESOTA - Medicaid NORTH CAROLINA - Medicaid Website: http://www.dhs.state.mn. us/ Website: http://www.ncdhhs.gov/dma Click on Health Care, then Medical Assistance Phone: 919-855-4100 Phone: 1-800-657-3629 MISSOURI - Medicaid NORTH DAKOTA - Medicaid Website: Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.ht http://www.nd.gov/dhs/services/medicalserv/medicai m d/ Phone: 573-751-2005 Phone: 1-800-755-2604 OKLAHOMA - Medicaid and CHIP UTAH - Medicaid and CHIP Website: http://www.insureoklahoma.org Website: http://health.utah.gov/upp Phone: 1-888-365-3742 Phone: 1-866-435-7414 OREGON - Medicaid and CHIP VERMONT- Medicaid Website: http://www.oregonhealthykids.gov Website: http://www.greenmountaincare.org/ http://www.hijossaludablesoregon.gov Phone: 1-800-250-8427 Phone: 1-877-314-5678 _ PENNSYLVANIA -Medicaid VIRGINIA - Medicaid and CHIP Website: http://www.dpw.state.pa.us/hipp Medicaid Website: http://www.dmas.virginia.gov/rcp- Phone: 1-800-692-7462 HIPP.htm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.famis.org/ CHIP Phone: 1-866-873-2647 RHODE ISLAND - Medicaid WASHINGTON - Medicaid Website: www.ohhs.ri.gov Website: Phone: 401-462-5300 http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm Phone: 1-800-562-3022 ext. 15473 SOUTH CAROLINA - Medicaid WEST VIRGINIA - Medicaid Website: http://www.scdhhs.gov Website: www.dhhr.wv.gov/bms/ Phone: 1-888-549-0820 Phone: 1-877-598-5820, HMS Third PartLiabilit SOUTH DAKOTA - Medicaid WISCONSIN - Medicaid Website: http://dss.sd.gov Website: http://www.badgercareplus.org/pubs/p- Phone: 1-888-828-0059 10095. htm Phone: 1-800-362-3002 TEXAS - Medicaid WYOMING - Medicaid Website: https://www.gethipptexas.com/ Website: Phone: 1-800-440-0493 http://health.wyo.gov/healthcarefin/equalitycare Phone: 307-777-7531 SPD 0714_City of Ashland V2 091614 84 To see if any more States have added a premium assistance program since July 31, 2012, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health & Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cros.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565 OMB Control Number 1210-0137 (expires 09/30/2013) SPD 0714_City of Ashland V2 091614 85 PLAN INFORMATION Name and Address of the Plan Sponsor City of Ashland 20 East Main Ashland, OR 97520 (541) 488-6002 Name and Address of the Designated Agent for Service of Legal Process Dave Kanner, City Administrator 20 East Main Ashland, OR 97520 541-488-6002 Name and Address of the Third Party Administrator PacificSource Health Plans PO Box 7068 Springfield, OR 97475-0068 (888) 977-9299 Fax: (541) 684-5264 cs@pacificsource.com Internal Revenue Service and Plan Identification Number The corporate tax identification number assigned by the Internal Revenue Service is 936002117. The plan number is 501. Benefit Year The benefit year is the 12-month period of time beginning January 1 and ending December 31. Method of Funding Benefits Health benefits are self-insured from the general assets and or trust funds of the Plan Sponsor and are not guaranteed under an insurance policy or contract. The Plan Sponsor may purchase excess risk insurance coverage which is intended to reimburse the Plan Sponsorfor certain losses incurred and paid under the plan by the Plan Sponsor. Such excess risk coverage, if any, is not part of the plan. The cost of the plan is paid with contributions by the Plan Sponsor and participating employees. The Plan Sponsor determines the amount of contributions to the plan, based on estimates of claims and administration costs. Payments out of the plan to health care providers on behalf of the covered person will be based on the provisions of the plan. SPD 0714_City of Ashland V2 091614 86 This page left intentionally blank. SPD 0714_City of Ashland V2 091614 87 SIGNATURE PAGE The effective date of the Preferred 90+200 VAR GF 0812 plan is July 1, 2014. It is agreed by the City of Ashland that the provisions of this document are correct and will be the basis for the administration of the Preferred 90+200 VAR GF 0812 plan. Dated this day of By Title SPD 0714_City of Ashland V2 091614 88 This page left intentionally blank. SPD 0714-City of Ashland V2 091614 89 a V CITY OF -ASHLAND City of Ashland - Parks Group No.: G0032482 Preferred 90+200 VAR GF 0812 Effective: July 1, 2014 Third Party Administrative Services Provided By: Pace *ic S 0urce SPD 0714_City of Ashland Parks Final SingleSource Self- Insured This page left intentionally blank. SPD 0714_City of Ashland Parks Final II INTRODUCTION Welcome to your City of Ashland (also referred to as 'the employer' or 'employer') group health plan. Your employer offers this coverage to help you and your family members stay well, and to protect you in case of illness or injury. Your plan includes a wide range of benefits and services, and PacificSource hopes you will take the time to become familiar with them. Your employer, who is also the Plan Sponsor, has prepared this document to help you understand how your plan works and how to use it. This document summarizes the benefits provided under the Preferred 90+200 VAR GF 0812 Plan (referred to as 'the plan' or 'this plan' throughout this document). Please read it carefully and thoroughly. Your benefits are affected by certain limitations and conditions, which require you to be a wise consumer of health services and to use only those services you need. Also, benefits are not provided for certain kinds of treatments or services, even if your health care provider recommends them. The plan is a self-insured medical plan intended to meet the requirements of Sections 105(b), 105(h), and 106 of the Internal Revenue Code so that the portion of the cost of coverage paid by your Plan Sponsor, and any benefits received by you through this plan, are not taxable income to you. Your specific tax treatment will depend on your personal circumstances; the plan does not guarantee any particular tax treatment. You are solely responsible for any and all federal, state, and local taxes attributable to your participation in this plan, and the plan expressly disclaims any liability for such taxes. The plan is 'self-insured,' which means benefits are paid from your employer's general assets and or trust funds and are not guaranteed by an insurance company. The Plan Sponsor has contracted with a Third Party Administrator to perform certain administrative services related to this plan. PacificSource Health Plans is the Third Party Administrator and provides administrative services for this plan on behalf of the Plan Sponsor. If anything is unclear to you, PacificSource's staff is available to answer your questions. Please give them a call or visit them on the Internet at PacificSource.com. PacificSource looks forward to serving you and your family. PacificSource Health Plans PO Box 7068, Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 Espanol (800) 624-6052, extension 1009 cs@pacificsource.com This document serves as the written Plan document and Summary Plan Description (SPD). It is very important that you review the entire document carefully to confirm a complete understanding of the benefits available, as well as your responsibility, under the plan. This document is written in simple, easy-to-understand language. Technical terms are printed in italics and defined in the Plan Terms and Definitions section. This document explains the services covered by the plan; the benefit summaries tell you how much this plan pays toward expenses and amounts for which you are responsible. As used in this document, the word 'year' refers to the benefit year, which is the 12-month period beginning January 1 and ending December 31. The word lifetime as used in this document refers to the period of time you or your eligible dependents participate in this plan or any other plan sponsored by the Plan Sponsor. Any amount you or your eligible dependents have accumulated toward the benefit maximum amounts, deductible, or out-of-pocket maximum of any immediately prior plan sponsored by the Plan Sponsor will be counted toward the benefit maximum amounts of this plan. The Plan Sponsor reserves the right to amend, modify, or terminate this plan in any manner, at any time, which may result in termination or modification of your coverage. If this plan is terminated, any plan assets will be used to pay for eligible expenses incurred prior to the plan's termination, and such expenses will be paid as provided under the terms of this plan prior to termination. If there is any conflict between this document and the underlying plan document(s), the plan document(s) control. SPD 0714_City of Ashland Parks Final III This page left intentionally blank. SPD 0714_City of Ashland Parks Final iv CONTENTS MEDICAL BENEFIT SUMMARY 3 PRESCRIPTION BENEFIT SUMMARY 5 CHIROPRACTIC CARE BENEFIT SUMMARY ............................................................10 ADDITIONAL ACCIDENT BENEFIT SUMMARY 12 VISION BENEFIT SUMMARY 14 DENTAL BENEFIT SUMMARY ....................................................................................18 ORTHODONTIA BENEFITS .........................................................................................20 USING THE PROVIDER NETWORK 22 Preferred Provider Organization (PPO) 22 What is a PPO .......................................................................................................................................22 Who is Your PPO ...................................................................................................................................22 About Your PPO ....................................................................................................................................22 Non-PPO Providers 23 Example of Provider Payment 23 Allowable Amount 23 NETWORK NOT AVAILABLE BENEFITS 23 COVERAGE WHILE TRAVELING 23 Nonemergency Care While Traveling ....................................................................................................24 Emergency Services While Traveling 24 FINDING PARTICIPATING PROVIDER INFORMATION 24 TERMINATION OF PROVIDER CONTRACTS 24 BECOMING ELIBIGLE 25 Who Pays for Your Benefits ...................................................................................................................25 Who is Eligible .......................................................................................................................................25 ENROLLING DURING THE INITIAL ENROLLMENT PERIOD 26 Newborns 26 Adopted Children 26 Foster Children ......................................................................................................................................26 Family Members Acquired by Marriage .................................................................................................26 Family Members Acquired by Domestic Partnership 27 Family Members Placed in Your Guardianship 27 Qualified Medical Child Support Orders 27 ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD 27 Returning to Work after a Layoff ............................................................................................................27 Returning to Work after a Leave of Absence 27 Returning to Work after Family Medical Leave 28 Special Enrollment Periods ....................................................................................................................28 Dental Enrollment ..................................................................................................................................28 Late Enrollment ......................................................................................................................................28 Member ID Card ....................................................................................................................................29 PLAN SELECTION PERIOD 29 TERMINATING COVERAGE 29 Divorced Spouses ..................................................................................................................................29 Dependent Children ...............................................................................................................................29 Dissolution of Domestic Partnership ......................................................................................................29 Certificates of Creditable Coverage 30 SPD 0714_City of Ashland Parks Final v CONTINUATION OF COVERAGE 30 USERRA CONTINUATION 30 Surviving or Divorced Spouses and Qualified Domestic Partners 30 COBRA CONTINUATION 31 COBRA Eligibility 31 When Continuation Coverage Ends 31 Type of Coverage 31 Your Responsibilities and Deadlines 32 Continuation Premium ...........................................................................................................................32 Keep Your Plan Informed of Address Changes 32 CONTINUATION WHEN YOU RETIRE ........................................................................32 WORK STOPPAGE 33 Labor Unions ..........................................................................................................................................33 COVERED EXPENSES 33 Medical Necessity ..................................................................................................................................33 Healthcare Providers 33 Your Annual Out-of-Pocket Limit 34 MEDICAL BENEFITS 34 About Your Medical Benefits 34 PLAN BENEFITS 35 PREVENTIVE CARE SERVICES 36 PROFESSIONAL SERVICES 38 HOSPITAL AND SKILLED NURSING FACILITY SERVICES 39 OUTPATIENT SERVICES 39 EMERGENCY SERVICES 40 MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES 41 Mental Health and Chemical Dependency Services .............................................................................41 Medical Necessity and Appropriateness of Treatment ..........................................................................42 HOME HEALTH AND HOSPICE SERVICES 42 DURABLE MEDICAL EQUIPMENT 43 TRANSPLANT SERVICES 44 Payment of Transplant Benefits .............................................................................................................45 OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS 45 BENEFIT LIMITATIONS AND EXCLUSIONS 48 Least Costly Setting for Services ...........................................................................................................48 EXCLUDED SERVICES 48 A Note About Optional Benefits .............................................................................................................48 Experimental or Investigational Treatment ............................................................................................52 EXCLUSION PERIODS 54 Exclusion Period for Transplant Benefits 54 CREDIT FOR PRIOR COVERAGE 54 Evidence of Prior Creditable Coverage 54 SPD 0714_City of Ashland Parks Final vi HEALTH CARE MANAGEMENT AND PREAUTHORIZATION 55 What is Health Care Management 55 Case Management 56 Individual Benefits Management ............................................................................................................56 HOW TO USE YOUR DENTAL PLAN 56 DENTAL PLAN BENEFITS 56 COVERED DENTAL SERVICES 57 Class I Services - Diagnostic and Preventive Treatment 57 Class II Restorative Services - Basic and Restorative Treatment 57 Class II Complicated Services - Complicated Treatment 58 Class I I I Services -Major Treatment 58 ORTHODONTIA BENEFITS .........................................................................................59 EXCLUDED DENTAL SERVICES 59 CLAIMS PROCEDURES 61 Questions about Your Claims 62 Types of Claims 62 How to File a Claim ................................................................................................................................62 Incomplete Claims .................................................................................................................................64 Notification of Benefit Determination .....................................................................................................65 Adverse Benefit Determination 65 Your Right to Appeal 65 Resources For Information And Assistance 68 Plan Sponsor's Discretionary Authority; Standard of Review ................................................................69 Coordination of Benefits .........................................................................................................................69 Order of Payment When Coordinating with Other Group Health Plans ................................................70 OTHER IMPORTANT PLAN PROVISIONS 71 Assignment of Benefits 71 Proof of Loss ..........................................................................................................................................71 No Verbal Modifications of Plan Provisions ...........................................................................................71 Reimbursement to the Plan ...................................................................................................................72 Subrogation 72 Recovery of Excess Payments 73 Right To Receive and Release Necessary Information .........................................................................73 Reliance on Documents and Information ...............................................................................................73 No Waiver 73 Physician/Patient Relationship ..............................................................................................................73 Plan not responsible for Quality of Health Care ....................................................................................74 Plan is not a Contract of Employment ...................................................................................................74 Right to Amend or Terminate Plan 74 Applicable Law .......................................................................................................................................74 PRIVACY AND CONFIDENTIALITY 74 Permitted Disclosures of Protected Health Information to the Plan Sponsor ........................................74 No Disclosure of Protected Health Information to the Plan Sponsorwithout Certification by Plan Sponsor 75 Conditions of Disclosure of Protected Health Information to the Plan Sponsor ....................................75 Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the Plan Sponsor 75 Required Separation between the Plan and the Plan Sponsor .............................................................76 DEFINITIONS 76 RIGHTS OF PLAN MEMBERS 85 SPD 0714_City of Ashland Parks Final vii This page left intentionally blank. SPD 0714_City of Ashland Parks Final viii Grandfathered Health Plan The Plan Sponsor believes this plan is a `grandfathered health plan' under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Plan Sponsor, or you may contact PacificSource at: PacificSource Health Plans PO Box 7068 Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 email: cs@pacificsource.com SPD 0714_City of Ashland Parks Final 1 This page left intentionally blank. SPD 0714_City of Ashland Parks Final 2 MEDICAL BENEFIT SUMMARY POLICY INFORMATION Group Name: City of Ashland Group Number: G0032482 Plan Name: Preferred 90+200 VAR GF 0812 Provider Network: Preferred PSN EMPLOYEE ELIGIBILITY REQUIREMENTS Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours Waiting Period for New Employees: 1 st day of the month following one (1) day. A person hired on the first day of the month is eligible on the first day of the following month. ANNUAL DEDUCTIBLE ..........................................$200 per person / $600 per family The deductible is an amount of covered medical expenses the member pays each benefit year before the plan's benefits begin. The deductible applies to all services and supplies except those marked with an asterisk Once a member has paid a total amount toward covered expenses during the benefit year equal to the per person amount listed above, the deductible will be satisfied for that person for the rest of that benefit year. Once any covered family members have paid a combined total toward covered expenses during the benefit year equal to the per family amount listed above, the deductible will be satisfied for all covered family members for the rest of that benefit year. Deductible expense is not applied to the out-of-pocket limit. ANNUAL OUT-OF-POCKET LIMIT Participating Providers $700 per person / $1,400 per family Non-participating Providers ..........................................$1,700 per person / $3,400 per family Only participating provider expense applies to the participating provider out-of-pocket limit and only non- participating provider expense applies to the non-participating out-of-pocket limit. Once the participating provider out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the co-payment is deducted) for participating and network not available providers for the rest of that benefit year. Once the non-participating provider out-of-pocket limit has been met, this plan will pay 100% of covered charges (after the co-payment is deducted) for non-participating providers for the rest of that benefit year. Deductibles, co-payments, transplants performed at a non-participating facility, benefits paid in full and non-participating provider charges in excess of the allowable fee do not accumulate toward the out-of-pocket limit. Co-payments and non-participating provider charges in excess of the allowable fee will continue to be the member's responsibility even after the out-of-pocket limit is met. ADDITIONAL ACCIDENT BENEFIT The first $1,000 of covered expenses within 90 days of an accident is covered at no charge and is not subject to the deductible. The balance is covered as shown below. The member is responsible for the above deductible and the following co-payments and co-insurance. PARTICIPATING PROVIDERS/ NON-PARTICIPATING SERVICE: NETWORK NOT AVAILABLE: PROVIDERS: PREVENTIVE CARE Well Baby/Well Child Care 10% co-insurance 30% co-insurance Routine Physicals No charge' No charge` Well Woman Visits No charge" No charge" Immunizations - 0-18 yrs No charge* No charge* Immunizations - age 19 and over 10% co-insurance 30% co-insurance Colonoscopy 10% co-insurance 30% co-insurance PROFESSIONAL SERVICES Office and Home Visits 10% co-insurance 30% co-insurance Office Procedures and Supplies 10% co-insurance 30% co-insurance Surgery 10% co-insurance 30% co-insurance Outpatient Rehabilitation Services 10% co-insurance 10% co-insurance HOSPITAL SERVICES Inpatient Room and Board 10% co-insurance 30% co-insurance Inpatient Rehabilitation Services 10% co-insurance 30% co-insurance Skilled Nursing Facility Care 10% co-insurance 30% co-insurance SPD 0714_City of Ashland Parks Final 3 OUTPATIENT SERVICES Outpatient Surgery/Services 10% co-insurance 30% co-insurance Advanced Diagnostic Imaging 10% co-insurance 30% co-insurance Diagnostic and Therapeutic Radiology 10% co-insurance 30% co-insurance and Lab URGENT AND EMERGENCY SERVICES Urgent Care Center Visits 10% co-insurance 30% co-insurance Emergency Room Visits $100 co-pay/visit plus $100 co-pay/visit plus 10/o co-insurance 10/o co-insurance Ambulance, Ground 10% co-insurance 10% co-insurance Ambulance, Air 10% co-insurance 10% co-insurance MENTAL HEALTH/CHEMICAL DEPENDENCY SERVICES Office Visits 10% co-insurance 30% co-insurance Inpatient Care 10% co-insurance 30% co-insurance Residential Programs 10% co-insurance 30% co-insurance OTHER COVERED SERVICES Allergy Injections 10% co-insurance 30% co-insurance Durable Medical Equipment 10% co-insurance 30% co-insurance Home Health Care 10% co-insurance 10% co-insurance Chiropractic Plus (12 visits/benefit 10% co-insurance 10% co-insurance year) ^ For emergency medical conditions, non-participating providers are paid at the participating provider level. * Not subject to annual deductible. Payment to providers is based on the prevailing or contracted PacificSource fee allowance for covered services. Although participating providers accept the fee allowance as payment in full, non-participating providers may not. Services of non- participating providers could result in out-of-pocket expense in addition to the cost share above. Network Not Available (NNA) payment is allowed when PacificSource has not contracted with providers in the geographical area of the member's residence or work for a specific service or supply. Payment to providers for NNA is based on the usual, customary, and reasonable charge for the geographical area in which the charge is incurred. SPD 0714_City of Ashland Parks Final 4 PRESCRIPTION BENEFIT SUMMARY Your Plan Sponsor's health plan includes coverage for prescription drugs and certain other pharmaceuticals, subject to the information below. Your prescription drug plan qualifies as creditable coverage for Medicare Part D. PRESCRIPTION DRUG OUT-OF-POCKET LIMIT $2,500 The co-payment and/or co-insurance for prescription drugs obtained from a participating pharmacy is waived at participating pharmacies during the remainder of a benefit year in which you have satisfied a Prescription Drug Out of Pocket Limit of $2,500. The limit applies to each member. Claims must be submitted by the participating pharmacy electronically. Differential between brand name and generic drugs, and drugs obtained at a non-participating pharmacy do not apply toward the limit. MEMBER COST SHARE (other than for Specialty Drugs) Effective July 1, 2014 - September 30, 2014 Each time a covered pharmaceutical is dispensed, you are responsible for the co-payment and/or co- insurance below: Tier 1: Tier 2: Tier 3: Generic Preferred Non-preferred From a participating retail pharmacy using the PacificSource Pharmacy Program (see below): Up to a 34-day supply: $5 $25 $50 From a participating mail order service (see below): Up to a 34-day supply: $5 $25 $50 35 to 90-day supply: $10 $50 $100 From a participating retail pharmacy without using Not covered, the PacificSource Pharmacy Program, or from a except 5-day emergency supply non-participating pharmacy (see below): MEMBER COST SHARE (other than for Specialty Drugs) Effective October 1, 2014 - June 30, 2015 Each time a covered pharmaceutical is dispensed, you are responsible for the co-payment and/or co- insurance below: Tier 1: Tier 2: Tier 3: Generic Preferred Non-preferred From a participating retail pharmacy using the PacificSource Pharmacy Program (see below): Up to a 34-day supply: $5 $25 $50 35 to 60-day supply: $10 $50 $100 61 to 94- day supply: $15 $75 $150 From a participating mail order service (see below): Up to a 34-day supply: $5 $25 $50 35 to 94-day supply $10 $50 $100 SPD 0714_City of Ashland Parks Final 5 From a participating retail pharmacy without using the PacificSource Pharmacy Program, or from a Not covered, non-participating pharmacy (see below): except 5-day emergency supply MEMBER COST SHARE FOR SPECIALTY DRUG Each time a covered specialty drug is dispensed, you are responsible for the co-payment and/or co- insurance below: From the participating specialty pharmacy: Up to a 30-day supply: Same as retail pharmacy co-payment above From a participating retail pharmacy, from a participating mail order service, or from a non- Not covered, participating pharmacy or pharmaceutical service except 5-day emergency supply provider: WHAT HAPPENS WHEN A BRAND NAME DRUG IS SELECTED Regardless of the reason or medical necessity, if you receive a brand name drug or if your physician prescribes a brand name drug when a generic is available, you will be responsible for the brand name drug's co-payment and/or co-insurance. USING THE PACIFICSOURCE PHARMACY PROGRAM Retail Pharmacy Network To use the PacificSource pharmacy program, you must show the pharmacy plan number on the PacificSource ID card at the participating pharmacy to receive your plan's highest benefit level. When obtaining prescription drugs at a participating retail pharmacy, the PacificSource pharmacy program can only be accessed through the pharmacy plan number printed on your PacificSource ID card. That plan number allows the pharmacy to collect the appropriate co-payment and/or co-insurance from you and bill PacificSource electronically for the balance. Mail Order Service This plan includes a participating mail order service for prescription drugs. Most, but not all, covered prescription drugs are available through this service. Questions about availability of specific drugs may be directed to the PacificSource Customer Service Department or to the plan's participating mail order service vendor. Forms and instructions for using the mail order service are available from PacificSource and on PacificSource's website, PacificSource.com. Specialty Drug Program PacificSource contracts with a specialty pharmacy services provider for high-cost injectable medications and biotech drugs. A pharmacist-led CareTeam provides individual follow-up care and support to covered members with prescriptions for specialty medications by providing them strong clinical support, as well as the best drug pricing for these specific medications and biotech drugs. The CareTeam also provides comprehensive disease education and counseling, assesses patient health status, and offers a supportive environment for patient inquiries. Participating provider benefits for specialty drugs are available when you use PacificSource's specialty pharmacy services provider. Specialty drugs are not available through the participating retail pharmacy network or mail order service. More information regarding PacificSource's exclusive specialty pharmacy services provider and health conditions and a list of drugs requiring preauthorization and/or are subject to pharmaceutical service restrictions is on PacificSource's website, PacificSource.com. OTHER COVERED PHARMACEUTICALS Supplies covered under the pharmacy plan are in place of, not in addition to, those same covered supplies under the medical plan. Member cost share for items in this section are applied on the same basis as for other prescription drugs, unless otherwise noted. Diabetic Supplies • Insulin, diabetic syringes, lancets, and test strips are available. SPD 0714_City of Ashland Parks Final 6 • Glucagon recovery kits are available for the plan's preferred brand name co-payment. • Glucostix and glucose monitoring devices are not covered under this pharmacy benefit, but are covered under the medical plan's durable medical equipment benefit. Contraceptives • Oral contraceptives • Implantable contraceptives, contraceptive injections, contraceptive patches, and contraceptive rings are available. • Diaphragm or cervical caps are available. Tobacco Cessation Program specific tobacco cessation medications are covered with active participation in a plan approved tobacco cessation program (see Preventive Care in the policy's Covered Expenses section). Orally Administered Anticancer Medications Orally administered anticancer medications used to kill or slow the growth of cancerous cells are available. Co-payments for orally administered anticancer medication are applied on the same basis as for other drugs. Orally administered anticancer medications covered under the pharmacy plan are in place of, not in addition to, those same covered drugs under the medical plan. LIMITATIONS AND EXCLUSIONS • This plan only covers drugs prescribed by a licensed physician (or other licensed practitioner eligible for reimbursement under your plan) prescribing within the scope of his or her professional license, except for: - Over-the-counter drugs or other drugs that federal law does not prohibit dispensing without a prescription (even if a prescription is required under state law). - Drugs for any condition excluded under the health plan. That includes drugs intended to promote fertility, treatments for obesity or weight loss, tobacco cessation drugs (except as specifically provided for under Other Covered Pharmaceuticals), experimental drugs, and drugs available without a prescription (even if a prescription is provided). - Some specialty drugs that are not self-administered are not covered by this pharmacy benefit, but are covered under the medical plan's office supply benefit. - Immunizations (although not covered by this pharmacy benefit, immunizations may be covered under the medical plan's preventive care benefit). - Drugs and devices to treat erectile dysfunction. - Drugs used as a preventive measure against hazards of travel. - Vitamins, minerals, and dietary supplements, except for prescription prenatal vitamins and fluoride products, and for services that have a rating of `A' or `B' from the U.S Preventive Services Task Force (USPSTF). • Certain drugs require preauthorization by PacificSource in order to be covered. An up-to-date list of drugs requiring preauthorization is available on PacificSource's website, PacificSource.com. • PacificSource may limit the dispensing quantity through the consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and governmental approval status. • Effective July 1, 2014 - September 30, 2014: Quantities for any drug filled or refilled are limited to no more than a 34-day supply when purchased at retail pharmacy or a 90-day supply when purchased through mail order pharmacy service or a 30-day supply when purchased through a specialty pharmacy. • Effective October 1, 2014 - June 30, 2015: Quantities for any drug filled or refilled are limited to no more than a 94-day supply when purchased at retail pharmacy or through mail order pharmacy service or a 30-day supply when purchased through a specialty pharmacy. • For drugs purchased at non-participating pharmacies or at participating pharmacies without using the PacificSource pharmacy program, reimbursement is limited to an allowable fee. SPD 0714_City of Ashland Parks Final 7 • Non-participating pharmacy charges are not eligible for reimbursement unless you have a true medical emergency that prevents you from using a participating pharmacy. Drugs obtained at a non-participating pharmacy due to a true medical emergency are limited to a 5 day supply. • The member cost share for prescription drugs (co-payments, co-insurance, and service charges) does not apply to the medical deductible or out-of-pocket limit of the policy. You continue to be responsible for the prescription drug co-payments and service charges regardless of whether the policy's out-of-pocket limit is satisfied. • Prescription drug benefits are subject to your plan's coordination of benefits provision. (For more information see Claims Payment - Coordination of Benefits in your Summary Plan Description.) GENERAL INFORMATION ABOUT PRESCRIPTION DRUGS A drug formulary is a list of preferred medications used to treat various medical conditions. The formulary for this plan is known as the Preferred Drug List (PDL). The drug formulary is used to help control rising healthcare costs while ensuring that you receive medications of the highest quality. It is a guide for your physician and pharmacist in selecting drug products that are safe, effective, and cost efficient. The drug formulary is made up of name brand products. A complete list of medications covered under the drug formulary is available on the For Members area on PacificSource's website, PacificSource.com. The drug formulary is developed by Caremark@ in cooperation with PacificSource. Non-preferred drugs are covered brand name medications not on the drug formulary. Generic drugs are equivalent to name brand medications. By law, they must have the same active ingredients as the brand name medication and are subject to the same standards of their brand name counterpart. Name brand medications lose their patent protection after a number of years. Any drug company can then produce the drug, and the manufacturer must pass the same strict FDA standards of quality and product safety as the original manufacturer. Generic drugs are less expensive than brand name drugs because there is more competition and there is no need to repeat costly research and development. Your pharmacist and physician are encouraged to use generic drugs whenever they are available. SPD 0714_City of Ashland Parks Final $ This page left intentionally blank. SPD 0714_City of Ashland Parks Final 9 CHIROPRACTIC CARE BENEFIT SUMMARY Your plan's chiropractic care benefit allows you to receive treatment from licensed chiropractors for medically necessary diagnosis and treatment of illness or injury. Refer to the Medical Benefit Summary for your co-payment and/or co-insurance information. PacificSource contracts with a network of chiropractors, so you can reduce your out-of-pocket expense by using one of the participating providers. For a listing of participating chiropractors in your area, please refer to your plan's participating provider directory, visit our website, Pacificsource.com, or call our Customer Service Department. Covered Services • Chiropractic manipulation, massage therapy, and any laboratory services, x-rays, radiology, and durable medical equipment provided by or ordered by a chiropractor. The combined benefit for all treatments, services, and supplies provided or ordered by a chiropractor is limited to 12 visits per person in any benefit year. Excluded Services • Any service or supply excluded or not otherwise covered by the medical plan. • Drugs, homeopathic medicines, or homeopathic supplies furnished by a chiropractor. • Services of an alternative care provider for pregnancy or childbirth. SPD 0714_City of Ashland Parks Final 10 This page left intentionally blank. SPD 0714_City of Ashland Parks Final ADDITIONAL ACCIDENT BENEFIT SUMMARY In the event of an injury caused by an accident, first dollar benefits are provided for covered expenses according to the following: Related Definitions `Accident' means an unforeseen or unexpected event causing injury that requires medical attention. `Injury' means bodily trauma or damage which is independent of disease or infirmity. The damage must be caused solely through external and accidental means. Injury, for the purpose of this benefit, does not include musculoskeletal sprains or strains obtained in the performance of physical activity. Covered Expenses Benefits for the following covered expenses are provided, subject to the limitations stated below: • Services or supplies provided by a physician (except orthopedic braces) • Services of a hospital • Services of a registered nurse who is unrelated to the injured person by blood or marriage • Services of a registered physical therapist • Services of a physician or a dentist for the repair of a fractured jaw or natural teeth • Diagnostic radiology and laboratory services • Transportation by local ground ambulance Limitations • The treatment must be medically necessary for the injury. • The treatment or service must be provided within 90 days after the injury occurs. • The first $1,000 of covered expense is paid at 100% and is not subject to the deductible. SPD 0714_City of Ashland Parks Final 12 This page left intentionally blank. SPD 0714_City of Ashland Parks Final 13 VISION BENEFIT SUMMARY Your Plan Sponsor covers vision exams, eyeglasses, and contact lenses. The following shows the vision benefits available. Member Responsibility PARTICIPATING NON-PARTICIPATING SERVICE/SUPPLY PROVIDERS: PROVIDERS: Eye Exam for members No charge No charge up to a $71 through Age 18 maximum Eye Exam for members Age 19 No Charge No charge up to a $71 and Older maximum Hardware for members No charge for one pair per Same benefits as members through Age 18 year for non-collection Age 19 and Older frames and/or lenses Hardware for members Age 19 and Older Lenses (maximum per pair) Single Vision No charge No charge up to a $51 maximum Bifocal No charge No charge up to a $77 maximum Trifocal No charge No charge up to a $100 maximum Lenticular No charge Not covered Progressive No charge Not covered Frames No charge up to a No charge up to a $120 maximum $66 maximum Contacts (in place of glasses) No charge up to a $166 No charge up to a $166 maximum maximum The amounts listed above are the maximum benefits available for all vision exams, lenses, and frames furnished during any benefit period when prescribed by a licensed ophthalmologist or licensed optometrist. Participating providers discount hardware services. Limitations and Exclusions The out-of-pocket expense for vision services (co-payments and service charges) does not apply to the medical plan's deductible or out-of-pocket limit. Also, the member continues to be responsible for the vision co-payments and service charges regardless of whether the medical plan's out-of-pocket limit is satisfied. Benefit Limitations: enrolled members through age 18 'Collection' lenses and/or frames refers to brand name hardware when comparable non- brand/non-collection lenses and/or frames are available. Collection glasses (lenses and frames) are not covered. • One vision exam every benefit year • One pair of non-collection glasses (lenses and frames) per benefit year. If the cost of the frame is over $175, preauthorization by PacificSource is required. • In lieu of eyeglasses, elective contact lens services and materials are covered in full with the following limitations per benefit year: o Standard = 1 contact lens per eye (total 2 lenses); OR o Monthly = 6 lenses per eye (total 12 lenses); OR SPD 0714_City of Ashland Parks Final 14 o Bi-weekly = 6 lenses per eye (total 12 lenses); OR o Dailies = 30 lenses per eye (total 60 lenses) Benefit Limitations: enrolled members age 19 and older • One vision exam every 24 months • Lenses: One pair every 24 months • Frames: Once every 24 months • Contact lenses: Once every 24 months • Elective contact lenses are in lieu of frames and lenses Covered expenses do not include, and no benefits are payable for: • Special procedures such as orthoptics or vision training • Special supplies such as sunglasses (plain or prescription) and subnormal vision aids • Tint • Plano contact lenses • Anti-reflective coatings and scratch resistant coatings • Separate charges for contact lens fitting • Replacement of lost, stolen, or broken lenses or frames • Duplication of spare eyeglasses or any lenses or frames • Nonprescription lenses • Visual analysis that does not include refraction • Services or supplies not listed as covered expenses • Eye exams required as a condition of employment, or required by a labor agreement or government body • Expenses covered under any worker's compensation law • Services or supplies received before this plan's coverage begins or after it ends • Charges for services or supplies covered in whole or in part under any other medical or vision benefits provided by the Plan Sponsor • Medical or surgical treatment of the eye SPD 0714_City of Ashland Parks Final 15 Important information about your vision benefits Your Plan Sponsor's health plan includes coverage for vision services, including prescription eyeglasses and contact lenses. To make the most of those benefits, it's important to keep in mind the following: • Participating Providers PacificSource is able to add value to your vision benefits by contracting with a network of vision providers. Those providers offer vision services at discounted rates, which are passed on to you in your benefits. • Paying for Services Please remember to show your current PacificSource ID card whenever you use your plan's benefits. PacificSource's provider contracts require participating providers to bill us directly whenever you receive covered services and supplies. Providers normally call PacificSource to verify your vision benefits. Participating providers should not ask you to pay the full cost in advance. They may only collect your share of the expense up front, such as co-payments and amounts over your plan's allowances. If you are asked to pay the entire amount in advance, tell the provider you understand they have a contract with PacificSource and should bill PacificSource directly. • Sales and Special Promotions Vision retailers often use coupons and promotions to bring in new business, such as free eye exams, two-for-one glasses, or free lenses with purchase of frames. Because participating providers already discount their services through their contract with PacificSource, your plan's participating provider benefits cannot be combined with any other discounts or coupons. You can use your plan's participating provider benefits, or you can use your plan's non-participating provider benefits to take advantage of a sale or coupon offer. If you do take advantage of a special offer, the participating provider may treat you as an uninsured customer and require full payment in advance. You can then send the claim to PacificSource yourself, and PacificSource will reimburse you according to your plan's non-participating provider benefits. PacificSource hopes this information helps clarify your vision benefits. If you or your provider have any questions about your benefits, please call PacificSource Customer Service at (541) 686-1242 from Eugene-Springfield or (888) 977-9299 from other areas. SPD 0714_City of Ashland Parks Final 16 This page left intentionally blank. SPD 0714_City of Ashland Parks Final 17 DENTAL BENEFIT SUMMARY POLICY INFORMATION Group Name: City of Ashland Group Number: G0032482 Plan Name: Preferred Incentive Dental $1500 VAR 0711 EMPLOYEE ELIGIBILITY REQUIREMENTS Minimum Hour Requirement: Full Time: 40 hours, Part Time: 20-39 hours Waiting Period for New Employees: 1 st day of the month following one (1) day. A person hired on the first day of the month is eligible on the first day of the following month. DENTAL BENEFIT SUMMARY Subject to all the terms of this Group Dental Policy, the Plan Sponsorwill pay a dental benefit for covered dental expenses incurred by a covered person. The dental benefit is a percentage of the usual, customary, and reasonable charge for covered dental expenses incurred, subject to an annual maximum benefit, and an annual deductible, as follows: Maximum Payment The amount payable by this plan for covered services received under Class I are unlimited. The maximum amount payable by this plan for covered Class II and Class III services received each benefit year, or portion thereof, for each eligible patient is limited to $1,500. PLAN PAYMENT SCHEDULE Class I Services- Plan pays 70% toward covered Class I Services - Diagnostic and Preventive Treatment. Class II Restorative Services- Plan pays 70% toward covered Class II Restorative Services - Restorative Treatment. Class II Complicated Services- Plan pays 70% toward covered Class II Complicated Services - Complicated Treatment:. Class III Services- Plan pays 70% toward covered Class I I I Services - Major Treatment. This plan pays the percentage indicated above toward Class I, II and III Services during the first year an individual is eligible. Payment increases 10 percent (to a maximum benefit of 100 percent) each successive benefit year for Class I, 11 and I II Services if the member visits a dentist at least once during the benefit year. Payment decreases 10 percent (to a minimum benefit of the percentage stated above) each successive benefit year if the member does not visit a dentist at least once during the previous benefit year. SPD 0714_City of Ashland Parks Final 18 This page left intentionally blank. SPD 0714_City of Ashland Parks Final 19 ORTHODONTIA BENEFITS Covered Charges The Plan Sponsorwill pay 50% of the usual, customary and reasonable for orthodontics for all covered individuals. Lifetime Maximum The maximum amount payable by the Plan Sponsor for orthodontic benefits to an eligible patient is $1,000 per lifetime. Exclusions and Limitations • The Plan Sponsorwill cease making payment for orthodontic treatment if the treatment ends for any reason prior to the completion of your case. • The Plan Sponsorwill not make any payments for the repair or replacement of an orthodontic appliance that was furnished under this coverage. • The Plan Sponsor's monthly or periodic payments for orthodontics shall cease if your eligibility is terminated. • The Plan Sponsor's obligation to make payments for orthodontic treatment that began prior to your eligibility date is calculated based on remaining balance at your initial eligibility date. The calculation will take into account the dentist's or orthodontist's normal payment pattern. The above-mentioned maximum will apply to this amount. SPD 0714_City of Ashland Parks Final 20 This page left intentionally blank. SPD 0714_City of Ashland Parks Final 21 USING THE PROVIDER NETWORK This section explains how your plan's benefits differ when you use participating and non-participating providers. This information is not meant to prevent you from seeking treatment from any provider if you are willing to take increased financial responsibility for the charges incurred. All healthcare providers are independent contractors. Neither your Plan Sponsor nor PacificSource can be held liable for any claim or damages for injuries you experience while receiving medical care. Preferred Provider Organization (PPO) What is a PPO A preferred provider organization (PPO) has made agreements with hospitals, physicians, practitioners, and other health care providers to discount the cost of services they provide. Who is Your PPO The Plan Sponsor has chosen PacificSource to provide PPO services for employees and eligible dependents in Oregon, Idaho, and Montana service areas and in bordering communities in southwest Washington. They also have an agreement with a nationwide provider network, The First Health@ Network. The First Health providers outside PacificSource's service area are also considered participating providers under your plan. A list of participating providers can be accessed through the PacificSource website: PacificSource.com or by calling PacificSource at (888) 977-9299. This list of participating providers is updated regularly. About Your PPO PacificSource has selected the participating physicians, practitioners, and hospitals after carefully reviewing their qualifications. Each health care provider has agreed to a contracted amount in payment for their services. Additionally, you cannot be `balanced billed' for the difference between the PPO contracted amount and the provider's normal billed charge for a particular service. You are only responsible for the deductible, co-payment, and/or co-insurance payment shown on the Medical Benefit Summary. Enrolling in this plan does not guarantee that a particular participating provider will remain a participating provideror that a particular participating providerwill provide members under this plan only with covered services. Members should verify a health care provider's status as a participating provider each time services are received from the health care provider. It is not safe to assume that when you are treated at a participating medical facility, all services are performed by participating providers. A list of participating providers can be accessed through the PacificSource website: PacificSource.com or by calling PacificSource at (888) 977-9299. Whenever possible, you should arrange for professional services such as surgery and anesthesiology to be provided by a participating provider. Doing so will help you maximize your benefits and limit your out-of- pocket expenses. The PPO benefits are outlined on the Medical Benefit Summary. You have a free choice of any health care provider, and the physician-patient relationship shall be maintained. Members, together with their health care provider, are ultimately responsible for determining the appropriate course of medical treatment, regardless of whether the plan will pay for all or a portion of the cost of such care. The participating providers are merely independent contractors; neither the plan, the Plan Sponsor, nor PacificSource makes any warranty as to the quality of care that may be rendered by any participating provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from this plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of the participating providers and/or a list of participating health care professionals SPD 0714_City of Ashland Parks Final 22 who specialize in obstetrics or gynecology, contact PacificSource at (888) 977-9299 or PO Box 7068, Springfield, OR 97475-0068. Non-PPO Providers When you receive services or supplies from a nonparticipating provider, your out-of-pocket expense is likely to be higher than if you had used a participating provider. Besides the non-PPO deductible, co- payment, and/or co-insurance amounts shown on the Medical Benefit Summary, you may become responsible for the provider's billed amount that exceeds the plan's allowable amount. Example of Provider Payment The following illustrates how payment could be made for a covered service billed at $120. In this example, the Medical Benefit Summary shows a participating providers co-insurance of 20 percent and a non-participating providers co-insurance of 30 percent. This is only an example; your plan's benefits may be different. Participating Non-participating Provider Provider Provider's usual billed charge $120 $120 PPO's negotiated provider discount $20 $0 Plan's allowable amount $100 $100 Percent of payment 20% 30% Plan's payment $80 $70 Patient's amount of allowable amount $20 $30 Charges above the allowable amount $0 $20 Patient's total payment to provider $20 $50 Percent of charge paid by plan 80% 58% Percent of charge paid by patient 20% 42% Allowable Amount The plan bases payment to nonparticipating providers on an allowable amount for the same services or supplies. Several sources are used to determine the allowable amount, depending on the service or supply and the geographical area where it is provided. The allowable amount may be based on data collected from the Centers for Medicare and Medicaid Services (CMS), Viant Health Payment Solutions, other nationally recognized databases, or PacificSource. NETWORK NOT AVAILABLE BENEFITS The term 'network not available' is used when a member does not have reasonable geographic access to a participating provider for a covered medical service or supply. If you live in an area without access to a participating provider for a specific service or supply, your plan's Network Not Available benefits apply. Here's how that works: • You seek treatment from a nearby non-participating provider of that service or supply. • PacificSource determines the allowable fee for that service or supply (the term `allowable fee' is explained above under the Non-participating Providers section). • PacificSource applies the Network Not Available benefit level stated in your Medical Benefit Summary to the allowable fee to calculate covered expenses. • You are responsible for any co-payments, co-insurance, deductibles, and amounts over the allowable fee. COVERAGE WHILE TRAVELING Your plan is powered by the PacificSource Network (PSN). The PSN Network covers Oregon, Idaho, Montana, southwest Washington, and eastern Washington. When you need medical services outside of the PSN Network, you can save out-of-pocket expense by using the participating providers available through The First Health@ Network. SPD 0714_City of Ashland Parks Final 23 Nonemergency Care While Traveling To find a participating provider outside the regions covered by the PacificSource Network, call The First Health® Network at (800) 226-5116. (The phone number is also printed on your PacificSource ID card for convenience.) Representatives are available at any time to help you find a participating physician, hospital, or other outpatient provider. Nonemergency care outside of the United States is not covered. • If a participating provider is available in your area, your plan's participating provider benefits will apply if you use a participating provider. • If a participating provider is not available in your area, your plan's Network Not Available benefits will apply. • If a participating provider is available but you choose to use a non-participating provider, your plan's non-participating provider benefits will apply. Emergency Services While Traveling In medical emergencies (see the Covered Expenses - Emergency Services section of this Summary Plan Description), your plan pays benefits at the participating provider level regardless of your location. Your covered expenses are based on PacificSource's allowable fee. If you are admitted to a hospital as an inpatient following the stabilization of your emergency condition, your physician or hospital should contact the PacificSource Health Services Department at (888) 691-8209 as soon as possible to make a benefit determination on your admission. If you are admitted to a non-participating hospital, PacificSource may require you to transfer to a participating facility once your condition is stabilized in order to continue receiving benefits at the participating provider level. FINDING PARTICIPATING PROVIDER INFORMATION You can find up-to-date participating provider information: • By asking your healthcare provider if he or she is a participating provider for your Plan Sponsor's plan. • On the PacificSource website, PacificSource.com. Simply click on 'Find a Provider' and you can easily look up participating providers or print your own customized directory. • By contacting the PacificSource Customer Service Department. PacificSource can answer your questions about specific providers. If you'd like a complete provider directory for your plan, just ask - PacificSource will be glad to mail you a directory free of charge. • By calling The First Health® Network at (800) 226-5116 if you live outside the area covered by the PacificSource Network. TERMINATION OF PROVIDER CONTRACTS PacificSource will notify you within ten days of learning of the termination of a provider contractual relationship if you have received services in the previous three months from such a provider when: • A provider terminates a contractual relationship with PacificSource in accordance with the terms and conditions of the agreement; • A provider terminates a contractual relationship with an organization under contract with PacificSource; or • PacificSource terminates a contractual relationship with an individual provider or the organization with which the provider is contracted in accordance with the terms and conditions of the agreement. For the purposes of continuity of care, PacificSource may require the provider to adhere to the medical services contract and accept the contractual reimbursement rate applicable at the time of contract termination. SPD 0714_City of Ashland Parks Final 24 BECOMING ELIBIGLE Who Pays for Your Benefits The Plan Sponsor shares the cost of providing benefits for you and your enrolled dependents. From time to time, the Plan Sponsor may adjust the amount of contributions required for coverage. In addition, the deductibles and co-payments may also change periodically. You will be notified by your Plan Sponsor of any changes in the cost of plan coverage before they take effect. Who is Eligible Employees - You are eligible to participate in this plan if you are a regular, full-time employee of the Plan Sponsor upon the completion of the minimum number of hours and probationary waiting period set by your Plan Sponsor. Your Plan Sponsor's eligibility requirements are stated in your Medical Benefit Summary. All employees who meet those requirements are eligible for coverage. Eligibility for Medicaid or the receipt of Medicaid benefits will not be taken into account in determining eligibility. Status as an employee is determined under the employment records of the Plan Sponsor. Workers classified by the Plan Sponsor as independent contractors are not eligible for this plan under any circumstances. Retirees - You are eligible to participate in this plan if you are a retired employee of the Plan Sponsor, or a spouse of a retired employee. Eligibility for Medicaid or the receipt of Medicaid benefits will not be taken into account in determining eligibility. Dependents - While you are enrolled under this plan, the following family members, and only the following family members, are also eligible to participate in the plan: • Your legal spouse or qualified domestic partner. The Plan Sponsor may require documentation proving a legal marital relationship, an Affidavit of Domestic Partnership or a Certificate of Qualified domestic partnership. • Your, your spouse's, or your qualified domestic partner's dependent children under age 26 regardless of the child's place of residence, marital status, or financial dependence on you. • Your, your spouse's, or your qualified domestic partner's unmarried dependent children age 26 or over who are mentally or physically disabled. To qualify as dependents, they must have been continuously unable to support themselves since turning age 26 because of a mental or physical disability. PacificSource requires documentation of the disability from the child's physician, and will review the case before determining eligibility for coverage. • Dependent family member. A brother, sister, niece, nephew or grandchild of an eligible dependent enrolled on your plan under age 26 who is unmarried, not in a domestic partnership, registered or otherwise, who is related to you by blood, marriage, or domestic partnership AND for whom you are the court appointed legal custodian or guardian with the expectation that the family member will live in your household for at least a year. • A child placed for adoption with you, your spouse, or qualified domestic partner. Placed for adoption means the assumption and retention by you, your spouse, or qualified domestic partner of a legal obligation for total or partial support of a child in anticipation of adoption or placement for adoption. Upon any termination of such legal obligations the placement for adoption shall be deemed to have terminated. • A foster child placed with you, your spouse, or your qualified domestic partner. Placement means an individual who is placed by an authorized placement agency or by judgment, decree, or other order of any court of competent jurisdiction. Coverage will continue assuming continued eligibility under this plan unless placement is disrupted and the child is removed from placement. • `Dependent children' means any natural, step, foster children or adopted children as well as any child placed for adoption with you or your domestic partner are legally obligated to support or contribute support for. • No family or household members other than those listed above are eligible to enroll under your coverage. Special Rules for Eligibility - At any time, the Plan Administrator may require proof that a person qualifies or continues to qualify as a dependent as defined by this plan. SPD 0714_City of Ashland Parks Final 25 ENROLLING DURING THE INITIAL ENROLLMENT PERIOD The `initial enrollment period' is the 60-day period beginning on the date a person is first eligible for enrollment in this plan. Everyone who becomes eligible for coverage has an initial enrollment period. When you satisfy your Plan Sponsor's probationary waiting period at the hours required for eligibility and become eligible to enroll in this plan, you and your eligible family members must enroll within the initial enrollment period. If you miss your initial enrollment period, you may be subject to a waiting period. (For more information, see 'Special Enrollment Periods' and 'Late Enrollment' under the Enrolling After the Initial Enrollment Period section.) To enroll, you must complete and sign an enrollment application, which is available from your Plan Sponsor. The application must include complete information on yourself and your enrolling family members. Return the application to your Plan Sponsor, and your Plan Sponsor will send it to PacificSource. Coverage for you and your enrolling family members begins on the first day of the month after you satisfy your Plan Sponsor's probationary waiting period. The probationary waiting period is stated in your Medical Benefit Summary. Coverage will only begin if Your Plan Sponsor receives your enrollment application and premium. Newborns Your, your spouse's, or your qualified domestic partner's natural born baby is eligible for enrollment under this plan during the 60-day initial enrollment period after birth. PacificSource cannot enroll the child and pay benefits until your Plan Sponsor receives an enrollment application listing the child as your dependent. A claim for maternity care is not considered notification for the purpose of enrolling a newborn child. Anytime there is a delay in providing enrollment information, your Plan Sponsor may ask for legal documentation to confirm validity. Adopted Children When a child is placed in your home for adoption, the child is eligible for enrollment under this plan during the 60-day initial enrollment period after placement for adoption. 'Placement for adoption' means the assumption and retention by you, your spouse, or your domestic partner of a legal obligation for full or partial support and care of the child in anticipation of adoption of the child. To add the child to your coverage, you must complete and submit an enrollment application listing the child as your dependent. You may be required to submit a copy of the certificate of adoption or other legal documentation from a court or a child placement agency to complete enrollment. If additional premium is required, then the natural born or adopted child's eligibility for enrollment will end 60 days after placement if Plan Sponsor has not received an enrollment application and premium. Premium is charged from the date of placement and prorated for the first month. If no additional premium is required, then the natural born or adopted child's eligibility continues as long as you are covered. However, PacificSource cannot enroll the child and pay benefits until your Plan Sponsor receives an enrollment application listing the child as your dependent. Foster Children When a foster child is placed in your home, you have 60 days from the date of placement to enroll them in your plan. To enroll the child, your Plan Sponsor must receive your enrollment application and additional premium within 60 days of the placement. Coverage for your new family members will begin on the date of placement. You may be required to submit a copy of the legal documentation from a court or a child placement agency to complete enrollment. Family Members Acquired by Marriage If you marry, you may add your new spouse and any newly eligible dependent children to your coverage during the 60-day initial enrollment period after the marriage. Your Plan Sponsor must receive your enrollment application and additional premium during the initial enrollment period. Coverage for your new family members will then begin on the first day of the month after the marriage. You may be required to submit a copy of your marriage certificate to complete enrollment. SPD 0714_City of Ashland Parks Final 26 Family Members Acquired by Domestic Partnership If you and your same-gender domestic partner have been issued a Certificate of Qualified domestic partnership, your domestic partner and your partner's dependent children are eligible for coverage during the 60-day initial enrollment period after the registration of the domestic partnership. Your Plan Sponsor must receive your enrollment application and additional premium during the initial enrollment period. Coverage for your new family members will then begin on the first day of the month after the registration of the domestic partnership. You may be required to submit a copy of your Certificate of Qualified domestic partnership to complete enrollment. Unregistered same-gender domestic partners and their children may also become eligible for enrollment. If you and your unqualified domestic partner meet the criteria on the Affidavit of Domestic Partnership supplied by your Plan Sponsor, your domestic partner and your partner's dependent children are eligible for coverage during the 60-day initial enrollment period after the requirements of the Affidavit of Domestic Partnership are satisfied. Your Plan Sponsor must receive your enrollment application, a copy of your Affidavit of Domestic Partnership, and additional premium during the initial enrollment period. Coverage for your new family members will then begin on the first day of the month after the Affidavit of Domestic Partnership is satisfied. Family Members Placed in Your Guardianship If a court appoints you custodian or guardian of an eligible dependent child, you may add that family member to your coverage. To be eligible for coverage, the family member must be: • Unmarried; • Not in a domestic partnership, registered or otherwise; • Related to you by blood, marriage, or domestic partnership; • Under age 26-1 and • Expected to live in your household for at least a year. Your Plan Sponsor must receive your enrollment application and additional premium during the 60-day initial enrollment period beginning on the date of the court appointment. Coverage will then begin on the first day of the month following the date of the court order. You may be required to submit a copy of the court order to complete enrollment. Qualified Medical Child Support Orders This health plan complies with qualified medical child support orders (QMCSO) issued by a state court or state child support agency. A QMCSO is a judgment, decree, or order, including approval of a settlement agreement that provides for health benefit coverage for the child of a plan member. If a court or state agency orders coverage for your spouse or child, they may enroll in this plan within the 60-day initial enrollment period beginning on the date of the order. Coverage will become effective on the first day of the month after Plan Sponsor receives the enrollment application. You may be required to submit a copy of the QMCSO to complete enrollment. ENROLLING AFTER THE INITIAL ENROLLMENT PERIOD Returning to Work after a Layoff If you are laid off and then rehired by your Plan Sponsor within six months, you will not have to satisfy another probationary waiting period or new exclusion period. Your health coverage will resume the first of the month following the date you return to work and again meet your Plan Sponsor's minimum hour requirement. If your family members were covered before your layoff, they can resume coverage at that time as well. You must re-enroll your family members by submitting an enrollment application within the 60-day initial enrollment period following your return to work. Returning to Work after a Leave of Absence If you return to work after a Plan Sponsor-approved leave of absence of six months or less, you will not have to satisfy another probationary waiting period. Your health coverage will resume the day you return to work and again meet your Plan Sponsor's minimum hour requirement. If your family members SPD 0714_City of Ashland Parks Final 27 were covered before your leave of absence, they can resume coverage at that time as well. You must re-enroll your family members by submitting an enrollment application within the 60-day initial enrollment period following your return to work. Returning to Work after Family Medical Leave Your Plan Sponsor is probably subject to the Family Medical Leave Act (FMLA). To find out if you have rights under FMLA, ask your health plan administrator. Under FMLA, if you return to work after a qualifying FMLA medical leave, you will not have to satisfy another probationary waiting period or any previously satisfied exclusion period under this plan. Your health coverage will resume the day you return to work and meet your Plan Sponsor's minimum hour requirement. If your family members were covered before your leave, they can also resume coverage at that time if you re-enroll them within the 60-day initial enrollment period following your return. Special Enrollment Periods If you are eligible to decline coverage and you wish to do so, you must submit a written waiver of coverage to your Plan Sponsor. You and your family members may enroll in this plan later if you qualify under Rule #1, Rule #2, or Rule #3 below. • Special Enrollment Rule #1 - If you declined enrollment for yourself or your family members because of other health insurance coverage, you or your family members may enroll in the plan later if the other coverage ends involuntarily. `Involuntarily' means coverage ended because continuation coverage was exhausted, employment terminated, work hours were reduced below the Plan Sponsor's minimum requirement, the other insurance plan was discontinued or the maximum lifetime benefit of the other plan was exhausted, the Plan Sponsor's premium contributions toward the other insurance plan ended, or because of death of a spouse, divorce, or legal separation. To do so, you must request enrollment within 60 days after the other health insurance coverage ends (or within 60 days after the other health insurance coverage ends if the other coverage is through Medicaid or a State Children's Health Insurance Program). Coverage will begin on the first day of the month after the other coverage ends. • Special Enrollment Rule #2 - If you acquire new dependents because of marriage, qualification of domestic partnership, birth, or placement for adoption, you may be able to enroll yourself and/or your newly acquired eligible dependents at that time. To do so, you must request enrollment within 60 days after the marriage, registration of the domestic partnership, birth, placement of foster child or placement for adoption. In the case of marriage or domestic partnership, coverage begins on the first day of the month after the marriage or registration of the domestic partnership. In the case of birth or placement for adoption, coverage begins on the date of birth or placement. • Special Enrollment Rule #3 - If you or your dependents become eligible for a premium assistance subsidy under Medicare or CHIP, you may be able to enroll yourself and/or your dependents at that time. To do so, you must request enrollment within 60 days of the date you and/or your dependents become eligible for such assistance. Coverage will begin on the first day of the month after becoming eligible for such assistance. Dental Enrollment Employees or their dependents who did not enroll with dental benefits when initially eligible may later enroll on the policy's anniversary date. Employees and/or dependents who enrolled with dental benefits under this policy but later terminated coverage may enroll on an anniversary date of the policy following a 24-month waiting period from the date coverage was last terminated. Late Enrollment If you did not enroll during your initial enrollment period and you do not qualify for a special enrollment period, your enrollment will be delayed until the plan's anniversary date. A 'late enrollee' is an otherwise eligible employee or dependent who does not qualify for a special enrollment period explained above, and who: • Did not enroll during the 60-day initial enrollment period; or • Enrolled during the initial enrollment period but discontinued coverage later. SPD 0714_City of Ashland Parks Final 28 A late enrollee may enroll by submitting an enrollment application to your Plan Sponsor during an open enrollment period designated by your Plan Sponsorjust prior to the plan's anniversary date. When you or your dependents enroll during the open enrollment period, plan coverage begins on the date Plan Sponsor receives the enrollment application or on the plan's anniversary date. You may enroll in coverage prior to an open enrollment period if one of the following exceptions are met: • You and/or your dependent may enroll in coverage if you involuntary lose other Group Coverage or lose coverage under the Oregon Health Plan. • You and/or your dependent may enroll in coverage if your hours per week are increased or your employer's contribution is increased. You and/or your dependent may also enroll if you return from a qualified FMLA leave. Member ID Card The membership card issued to you by PacificSource is for identification purposes only. Possession of a membership card confers no right to services or benefits under this plan and misuse of your membership card may be grounds for termination of your coverage under this plan. To be eligible for services or benefits under this plan, you must be eligible and enrolled in the plan and you must present the membership card to your health care provider. If you receive services or benefits for which you are not entitled to receive under the terms of this plan, you may be charged for such services or benefits at the prevailing rate. If you permit the use of your membership card by any other person, your card may be retained by this plan, and all your rights under this plan may be terminated. PLAN SELECTION PERIOD If your Plan Sponsor offers more than one benefit plan option, you may choose another plan option only upon your plan's anniversary date. You may select a different plan option by completing a selection form or application form. Coverage under the new plan option becomes effective on your plan's anniversary date. TERMINATING COVERAGE If you leave your job for any reason or your work hours are reduced below your Plan Sponsor's minimum requirement, coverage for you and your enrolled family members will end. Coverage ends on the last day of the last month in which you worked full time. You may, however, be eligible to continue coverage for a limited time; please see the Continuation section of this Summary Plan Description for more information. You can voluntarily discontinue coverage for your enrolled family members at any time by completing a Termination of Dependent Coverage form and submitting it to your Plan Sponsor. Keep in mind that once coverage is discontinued, your family members may be subject to the late enrollment waiting period if they wish to re-enroll later. Divorced Spouses If you divorce, coverage for your spouse will end on the last day of the month in which the divorce decree or legal separation is final. You must notify your Plan Sponsor of the divorce or separation, and continuation coverage may be available for your spouse. If there are special child custody circumstances, please contact your Plan Sponsor. Please see the Continuation section for more information. Dependent Children When your enrolled child no longer qualifies as a dependent, coverage will end on the last day of that month. Please see the Eligibility section of this Summary Plan Description for information on when your dependent child is eligible beyond age 25. The Continuation section includes information on other coverage options for those who no longer qualify for coverage. Dissolution of Domestic Partnership If you dissolve your domestic partnership, coverage for your domestic partner and their children not related to you by birth or adoption will end on the last day of the month in which the dissolution of the SPD 0714_City of Ashland Parks Final 29 domestic partnership is final. You must notify your Plan Sponsor of the dissolution of the domestic partnership. Domestic partners and their covered children are not recognized as qualified beneficiaries under federal COBRA continuation laws. Domestic partners and their covered children may not continue this policy's coverage under COBRA independent of the employee (see COBRA Continuation in the Continuation of Coverage section). Certificates of Creditable Coverage A certificate of creditable coverage is used to verify the dates of your prior health plan coverage when you apply for coverage under a new policy. These certificates are issued by health insurers whenever a plan participant's coverage ends. After your or your dependent's coverage under this plan ends, you will receive a certificate of creditable coverage by mail. PacificSource has an automated process that generates and mails these certificates whenever coverage ends. PacificSource will send a separate certificate for any dependents with an effective or termination date that differs from yours. For questions or requests regarding certificates of creditable coverage, you are welcome to contact Membership Services Department at (541) 684-5583 or (866) 999-5583. CONTINUATION OF COVERAGE Under federal and state laws, you and your family members may have the right to continue this plan's coverage for a specified time. You and your dependents may be eligible if: • Your employment ends or you have a reduction in hours • You take a leave of absence for military service • You divorce • You die • You become eligible for Medicare benefits if it causes a loss of coverage for your dependents • Your children no longer qualify as dependents The following sections describe your rights to continuation under state and federal laws, and the requirements you must meet to enroll in continuation coverage. USERRA CONTINUATION If you take a leave of absence from your job due to military service, you have continuation rights under the Uniformed Services Employment and Re-employment Rights Act (USERRA). You and your enrolled family members may continue this plan's coverage if you, the employee, no longer qualify for coverage under the plan because of military service. Continuation coverage under USERRA is available for up to 24 months while you are on military leave. If your military service ends and you do not return to work, your eligibility for USERRA continuation coverage will end. Premium for continuation coverage is your responsibility. The following requirements apply to USERRA continuation: • Family members who were not enrolled in the group plan cannot take continuation. The only exceptions are newborn babies and newly acquired dependents not covered by another group health plan. • To apply for continuation, you must submit a completed Continuation Election Form to your Plan Sponsor within 60 days after the last day of coverage under the group plan. • You must pay continuation premium to your Plan Sponsor by the first of each month. Your Plan Sponsorwill include your continuation premium in the group's regular monthly payment. PacificSource cannot accept the premium directly from you. • Your Plan Sponsor must still be self-insured through PacificSource. If your Plan Sponsor discontinues this plan, you will no longer qualify for continuation. Surviving or Divorced Spouses and Qualified Domestic Partners If you die, divorce, or dissolve your qualified domestic partnership, and your spouse or qualified domestic partner is 55 years or older, your spouse or qualified domestic partner may be able to SPD 0714_City of Ashland Parks Final 30 continue coverage until eligible for Medicare or other coverage. Dependent children are subject to the health plan's age and other eligibility requirements. Some restrictions and guidelines apply; please see your Plan Sponsorfor specific details. COBRA CONTINUATION Your Plan Sponsor is subject to the continuation of coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) as amended. To find out if you have continuation rights under COBRA, ask your health plan administrator. COBRA Eligibility To be eligible, a member must experience a 'qualifying event' which is an event that causes your regular group coverage to end and makes you eligible for continuation coverage. When the following qualifying events happen, you may continue coverage for the lengths of time shown: Qualifying Event Continuation Period Employee's termination of employment or reduction in Employee, spouse, and children may continue for up to hours 18 months Employee's divorce or legal separation Souse and children may continue for u to 36 months Employee's eligibility for Medicare benefits if it causes a Spouse and children may continue for up to 36 months loss of coverage Employee's death Souse and children may continue for u to 36 months Child no longer qualifies as a dependent Child may continue for u to 36 months Employer files for Chapter 11 bankruptcy Onl applies to retirees and their covered dependents If the employee or covered dependent is determined disabled by the Social Security Administration within the first 60 days of continuation coverage, all qualified beneficiaries may continue coverage for up to an additional 11 months, for a total of up to 29 months. 2 The total maximum continuation period is 36 months, even if there is a second qualifying event. A second qualifying event might be a divorce, legal separation, death, or child no longer qualifying as a dependent after the employee's termination or reduction in hours. If your dependents were not covered prior to your qualifying event, they may enroll in the continuation coverage while you are on continuation. They will be subject to the same rules that apply to active employees, including the late enrollment waiting period. If your employment is terminated for gross misconduct, you and your dependents are not eligible for COBRA continuation. Domestic partners and their covered children may not continue this policy's coverage under COBRA independent of the employee. When Continuation Coverage Ends Your continuation coverage will end before the end of the continuation period above if any of the following occur: • Your continuation premium is not paid on time. • You become covered under another group health plan that does not exclude or limit treatment for your pre-existing conditions. • You become entitled to Medicare benefits. • Your Plan Sponsor discontinues its health plan and no longer offers a group health plan to any of its employees. • Your continuation period was extended from 18 to 29 months due to disability, and you are no longer considered disabled. Type of Coverage Under COBRA, you may continue any coverage you had before the qualifying event. If your Plan Sponsor provides both medical and dental coverage and you were enrolled in both, you may continue both medical and dental. If your Plan Sponsor provides only one type of coverage, or if you were enrolled in only one type of coverage, you may continue only that coverage. SPD 0714_City of Ashland Parks Final 31 COBRA continuation benefits are always the same as your Plan Sponsor's current benefits. Your Plan Sponsor has the right to change the benefits of its health plan or eliminate the plan entirely. If that happens, any changes to the group health plan will also apply to everyone enrolled in continuation coverage. Your Responsibilities and Deadlines You must notify your Plan Sponsor within 60 days if you divorce, or if your child no longer qualifies as a dependent. That will allow your Plan Sponsor to notify you or your dependents of your continuation rights. When your Plan Sponsor learns of your eligibility for continuation, your Plan Sponsorwill notify you of your continuation rights and provide a Continuation Election Form. You then have 60 days from that date or 60 days from the date coverage would otherwise end, whichever is later, to enroll in continuation coverage by submitting a completed Election Form to your Plan Sponsor. If continuation coverage is not elected during that 60-day period, coverage will end on the last day of the last month you were an active employee. If you do not provide these notifications within the time frames required by COBRA, Plan Sponsor's responsibility to provide coverage under the health plan will end. Continuation Premium You or your family members are responsible for the full cost of continuation coverage. The monthly premium must be paid to your Plan Sponsor. PacificSource cannot accept continuation premium directly from you. You may make your first premium payment any time within 45 days after you return your Continuation Election Form to your Plan Sponsor. After the first premium payment, each monthly payment must reach your Plan Sponsorwithin 30 days of your Plan Sponsor's premium due date. If your Plan Sponsor does not receive your continuation premium on time, continuation coverage will end. If your coverage is canceled due to a missed payment, it will not be reinstated for any reason. Premium rates are established annually and may be adjusted if the plan's benefits or costs change. Keep Your Plan Informed of Address Changes In order to protect your and your family's rights, you should keep the Plan Sponsor informed of any changes in your address and the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Sponsor. CONTINUATION WHEN YOU RETIRE If you retire, you and your insured dependents are eligible to continue coverage subject to the following: • You must apply for continued coverage within 60 days after retirement. • You must be receiving benefits from PERS (Public Employee Retirement System) or from a similar retirement plan offered by your Plan Sponsor. • You will have the same opportunity to switch to another plan during the open enrollment period as do active employees. If the plan's benefits are changed by the policyholder, your benefits will change accordingly. • Except for newly acquired dependents due to marriage, registration of domestic partnership, birth, or adoption, only your dependents who were covered at the time of retirement may continue coverage under this provision. You may add a new spouse, domestic partner, or other newly acquired dependent after retirement if family coverage is available. A completed enrollment application must be submitted within 60 days of the date of marriage, registration of domestic partnership, birth, or adoption. Your continuation coverage will end when any one of the following occurs: • When full premium is not paid or when your coverage is voluntarily terminated, your coverage will end on the last day of the month for which premium was paid. • When you become eligible for Medicare coverage, your coverage will end on the last day of the month preceding Medicare eligibility. • When the regular group policy is terminated, your coverage will end on the date of termination. SPD 0714_City of Ashland Parks Final 32 Your dependent's continuation coverage will end when any one of the following occurs: • When full premium for the dependent is not paid or when the dependent's coverage is voluntarily terminated by you or your dependent, coverage will end on the last day of the month for which premium was paid. • When your dependent becomes eligible for Medicare coverage, your dependent's coverage will end on the last day of the month preceding Medicare eligibility. • When you die, divorce, or dissolve your domestic partnership, your dependent's coverage will end on the last day of the month following the death, divorce, or dissolution of the domestic partnership. • When your dependent is otherwise no longer considered a dependent under the group plan, his or her coverage will end on the last day of the month of their eligibility. Continuation of coverage may be available under COBRA continuation (see Continuation of Coverage provisions). • When the regular group policy is terminated, your dependent's coverage will end on the date of termination. WORK STOPPAGE Labor Unions If you are a union member, you have certain continuation rights in the event of a labor strike. Your union is responsible for collecting your premium and can answer questions about coverage during the strike. EXTENSION OF BENEFITS If you are on a Plan Sponsor-approved non-FMLA leave of absence, you may continue coverage under active status for up to three months by self-pay to the Plan Sponsor. Absences extending beyond three months will be subject to the Continuation of Coverage provisions of this plan. COVERED EXPENSES This plan provides comprehensive medical coverage when care is medically necessary to treat an illness or injury. Be careful -just because a treatment is prescribed by a healthcare professional does not mean it is medically necessary under the terms of the plan. Also remember that just because a service or supply is a covered benefit under this plan does not necessarily mean all billed charges will be paid. Some medically necessary services and supplies may be excluded from coverage under this plan. Be sure you read and understand the Benefit Limitations and Exclusions section of this book, including the section on Preauthorization. If you ever have a question about your plan benefits, contact the PacificSource Customer Service Department. Medical Necessity Except for specified Preventive Care services, the benefits of this health plan are paid only toward the covered expense of medically necessary diagnosis or treatment of illness or injury. This is true even though the service or supply is not specifically excluded. All treatment is subject to review for medical necessity. Review of treatment may involve prior approval, concurrent review of the continuation of treatment, post-treatment review or any combination of these. For additional information, see 'medically necessary' in the Definitions section of this Summary Plan Description. Be careful. Your healthcare provider could prescribe services or supplies that are not covered under this plan. Also, just because a service or supply is a covered benefit does not mean all related charges will be paid. Healthcare Providers This plan provides benefits only for covered expenses and supplies rendered a physician (M.D. or O.D.), practitioner, nurse, hospital or specialized treatment facility, durable medical equipment supplier, or other licensed medical provider as specifically stated in this Summary Plan Description. The services or supplies provided by individuals or companies that are not specified as eligible practitioners are not SPD 0714_City of Ashland Parks Final 33 eligible for reimbursement under the benefits of this plan. For additional information, see `practitioner', `specialized treatment facility', and `durable medical equipment supplier' in the Definitions section of this Summary Plan Description. Your Annual Deductible Deductible Carryover. The deductible must be satisfied only once in any benefit year, even though there may be several conditions treated. Covered expenses incurred during the last three (3) months of the previous benefit year will be applied to the subsequent year's benefit year deductible subject to the following: • The covered expenses were applied to the deductible; • The covered expenses were incurred during the last three (3) months of the year; and • The prior year's deductible was not satisfied. Final determination of which expenses apply to the deductible will be based on the order in which charges are incurred, even if bills for charges are not received in that order. Your Annual Out-of-Pocket Limit This plan has an out-of-pocket limit provision to protect you from excessive medical expenses. The Medical Benefit Summary shows your plan's annual out-of-pocket limits for participating and/or nonparticipating providers. If you incur covered expenses over those amounts, this plan will pay 100 percent of eligible charges, subject to the allowable fee. Your expenses for the following do not count toward the annual out-of-pocket limit: • Charges applied to deductible, if applicable to your plan • Co-payments, if applicable to your plan • Prescription drugs • Charges over the allowable fee for services of non-participating providers • Incurred charges that exceed amounts allowed under this plan Charges over the allowable fee for services of non-participating providers, and incurred charges that exceed amounts allowed under this plan, and co-payments will continue to be your responsibility even after the out-of-pocket or stop-loss limit is reached. Prescription drug benefits are not affected by the out-of-pocket or stop-loss limit. You will still be responsible for that co-payment or co-insurance payment even after the out-of-pocket or stop-loss limit is reached. MEDICAL BENEFITS About Your Medical Benefits All benefits provided under this plan must satisfy some basic conditions. The following conditions are commonly included in health benefit plans but are often overlooked or misunderstood. Medical Necessity - The plan provides benefits only for covered services and supplies that are medically necessary for the treatment of a covered illness or injury. Be careful-just because a treatment is prescribed by a healthcare professional does not necessarily mean it is medically necessary as defined by the plan. And, some medically necessary services and supplies may be excluded from coverage. Also, the treatment must not be experimental and/or investigational. Allowable Fees - The plan provides benefits only for covered expenses that are equal to or less than the allowable amount, as defined by the plan, in the geographic area where services or supplies are provided. Any amounts that exceed the allowable amount are not recognized by the plan for any purpose. Health Care Provider - The plan provides benefits only for covered expenses and supplies rendered by a physician, practitioner, nurse, hospital or specialized treatment facility, durable medical equipment supplier, or other licensed medical provider as specifically stated in this plan summary. The services or supplies provided by individuals or companies that are not specified as eligible practitioners are not SPD 0714_City of Ashland Parks Final 34 eligible for reimbursement under the benefits of this plan. For additional information, see practitioner, specialized treatment facility, and durable medical equipment in the Definitions section of this document. Custodial Care Providers - The plan does not provide benefits for services and supplies that are furnished primarily to assist an individual in the activities of daily living. Activities of daily living include such things as bathing, feeding, administration of oral medications, academic, social, or behavior skills training, and other services that can be provided by persons without the training of a health care practitioner. Benefit Year - The word year, as used in this document, refers to the benefit year, which is the 12- month period beginning January 1 and ending December 31. Unless otherwise specified, all annual benefit maximums and deductibles accumulate during the benefit year. Deductibles - A deductible is the amount of covered expenses you must pay during each year before the plan will consider expenses for reimbursement. The individual deductible applies separately to each covered person. The family deductible applies collectively to all covered persons in the same family. When the family deductible is satisfied, no further deductible will be applied for any covered family member during the remainder of the year. The annual individual and family deductible amounts are shown on the Medical Benefit Summary. Benefit Percentage Payable - Benefit percentage payable represents the portion of covered expenses paid by the plan after you have satisfied any applicable deductible. These percentages apply only to covered expenses which do not exceed the allowable amount. You are responsible for all remaining covered and non-covered expenses, including any amount that exceeds the allowable amount for covered services. The benefit percentages payable are shown on the Medical Benefit Summary. Co-payments - Co-payments are the first-dollar amounts you must pay for certain covered services, which are usually paid at the time the service is performed (i.e. physician office visits or emergency room visits). These co-payments do not apply to your annual deductible or out-of-pocket maximum, unless otherwise specified on the Medical Benefit Summary. The co-payment amounts are shown on the Medical Benefit Summary. Out-Of-Pocket Maximum(s) - An out-of-pocket maximum is the maximum amount of covered expenses you must pay during a year, before the plan's benefit percentage payable increases. The individual out-of-pocket maximum applies separately to each covered person. When a covered person reaches the annual out-of-pocket maximum, the plan will pay 100% of additional covered expenses for that individual during the remainder of that year, subject to the lifetime maximum amount, if applicable. However, expenses for services which do not apply to the out-of-pocket maximum will never be paid at 100%. The annual individual and family out-of-pocket maximum amounts are shown on the Medical Benefit Summary. Benefit Maximums - Total plan payments for each covered person are limited to certain maximum benefit amounts. A benefit maximum can apply to specific benefit categories or to all benefits. A benefit maximum amount may also apply to a specific time period, such as annual. Least Costly Setting For Services - Benefits of the plan provide for reimbursement of covered services performed in the least costly setting where services can be safely provided. If a procedure can be done safely in an outpatient setting but is performed in a hospital inpatient setting, this plan will only pay what it would have paid for the procedure on an outpatient basis. If services are performed in an inappropriate setting, your benefits may be reduced. PLAN BENEFITS This plan provides benefits for the following services and supplies as outlined on your Medical Benefit Summary. These services and supplies may require you to satisfy a deductible, make a co-payment, or both, and they may be subject to additional limitations or maximum dollar amounts. For a medical expense to be eligible for payment, you must be covered under this plan on the date the expense is incurred. Please refer to your Medical Benefit Summary and the Benefit Limitations and Exclusions section of this Summary Plan Description for more information. SPD 0714_City of Ashland Parks Final 35 Accident Benefit In the event of an injury caused by an accident the plan benefit will be as follows: The first $1,000 of covered expenses within 90 days of an accident is covered at no charge and is not subject to the deductible. The balance is covered as stated in your Medical Benefit Summary for covered expense. `Accident' means an unforeseen or unexpected event causing injury which requires medical attention. 'Injury' means bodily trauma or damages which is independent of disease or infirmity. The damage must be caused solely through external and accidental means. For the purpose of this benefit, injury does not include musculoskeletal sprains or strains obtained in the performance of physical activity. PREVENTIVE CARE SERVICES This plan covers the following preventive care services when provided by a physician, physician assistant, or nurse practitioner: • Routine physicals for members age 22 and older according to the following schedule: - Ages 22 and over One exam every benefit year Only laboratory work tests and other diagnostic testing procedures related to the routine physical exam are covered by this benefit. Any laboratory tests and other diagnostic testing procedures ordered during, but not related to, a routine physical examination are not covered by this preventative care benefit. Please see Outpatient Services in this section. • Well woman visits, including the following: One routine gynecological exam each benefit year for women 18 and over. Exams may include Pap smear, pelvic exam, breast exam, blood pressure check, and weight check. Exams may also include an annual mammogram for women over the age of 40, once between the ages of 35-40 unless medically necessary, for the purpose of early detection. Covered lab services are limited to occult blood, urinalysis, and complete blood count. Routine preventive mammograms for women as recommended. o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for 'Preventive Care - Well Woman Visits' applies to mammograms that are considered 'routine' according to the guidelines of the U.S. Preventive Services Task Force. o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for 'Outpatient Services - Diagnostic and Therapeutic Radiology and Lab' applies to diagnostic mammograms related to the ongoing evaluation or treatment of a medical condition. Pelvic exams and Pap smear exams at any time upon referral of a women's healthcare provider; and pelvic exams and Pap smear exams annually for women 18 to 64 years of age with or without a referral from a women's healthcare provider. Breast exams annually for women 18 years of age or older or at any time when recommended by a women's healthcare provider for the purpose of checking for lumps and other changes for early detection and prevention of breast cancer. • Colorectal cancer screening exams and lab work including the following: - A fecal occult blood test once per benefit year - A flexible sigmoidoscopy every five benefit years - A colonoscopy for age 50+ every ten benefit years o The deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for 'Preventive Care - Routine Colonoscopy' applies to colonoscopies that are considered 'routine' according to the guidelines of the U.S. Preventive Services Task Force. c The deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for 'Professional Services - Surgery' and for 'Outpatient Services - Outpatient Surgery/Services' apply to colonoscopies related to ongoing evaluation or treatment of a medical condition. SPD 0714_City of Ashland Parks Final 36 A double contrast barium enema every five benefit years A colonoscopy performed for screening purposes on individuals at `high risk' under age 50 is also considered a preventive service. An individual is at high risk for colorectal cancer if the individual has: o Family medical history of colorectal cancer; o Prior occurrence of cancer or precursor neoplastic polyps; o Prior occurrence of a chronic digestive disease condition such as inflammatory bowel disease, o Crohn's disease or ulcerative colitis; or o Other predisposing factors. • Prostate cancer screening, every two benefit years. Exams may include a digital rectal examination and a prostate-specific antigen test. Screenings apply to outpatient surgery/services benefit regardless of whether they are preventive or diagnostic. • Well baby/well child care exams for members age 21 and younger according to the following schedule: - At birth: One standard in-hospital exam - Ages 0 - 2: 12 additional exams during first 36 months of life - Ages 3 - 21: One exam per benefit year Newborn circumcision is a covered benefit even if performed several days after birth. Only laboratory tests and other diagnostic testing procedures related to a well baby/child care exam are covered by this plan. Any laboratory tests and other diagnostic testing procedures ordered during, but not related to, a well baby/child care exam are not covered by this preventative care benefit. Please see Outpatient Services in this section. • Standard age-appropriated childhood and adult immunizations for primary prevention of infectious diseases as recommended by and adopted the Centers for Disease Control and Prevention, American Academy of Pediatrics, American Academy of Family Physicians, or similar standard- setting body. Benefits do not include immunizations for more elective, investigative, unproven, or discretionary reasons (e.g. travel). Covered immunizations include, but may not be limited to the following: Diphtheria, pertussis, and tetanus (DPT) vaccines, given separately or together Hemophilus influenza B vaccine Hepatitis A vaccine Hepatitis B vaccine Human papillomavirus (HPV) vaccine Influenza vaccine Measles, mumps, and rubella (MMR) vaccines, given separately or together Meningococcal (meningitis) vaccine Pneumococcal vaccine Polio vaccine Varicella (chicken pox) vaccine • Tobacco use cessation program services are covered only when provided by a PacificSource approved program. Approved programs are covered at 100% of the cost up to a maximum lifetime benefit of two quit attempts. Approved programs are limited to members age 15 or older. Specific nicotine replacement therapy will only be covered according to the program's description. If this policy includes benefits for prescription drugs, tobacco use cessation related medication prescribed in conjunction with an approved tobacco use cessation program will be covered to the same extent this policy covers other prescription medications. SPD 0714_City of Ashland Parks Final 37 PROFESSIONAL SERVICES This plan covers the following professional services when medically necessary: • Services of a physician (M.D. or D.O.) for diagnosis or treatment of illness or injury • Services of a licensed physician assistant under the supervision of a physician • Services of a certified surgical assistant, surgical technician, or registered nurse (R.N.) when providing medically necessary services as a surgical first assistant during a covered surgery • Services of a nurse practitioner, including certified registered nurse anesthetist (C.R.N.A.) and certified nurse midwife (C.N.M.), for medically necessary diagnosis or treatment of illness or injury • Urgent care services provided by a physician. Urgent care is unscheduled medical care for an illness, injury, or disease that a prudent lay person would consider not life-threatening and treatable at urgent care. Examples of urgent care situations include sprains, cuts, and illnesses that do not require immediate medical attention in order to prevent seriously damaging the health of the person. • Outpatient rehabilitative services provided by a licensed physical therapist, occupational therapist, speech language pathologist, physician, or other practitioner licensed to provide physical, occupational, or speech therapy. Services must be prescribed in writing by a licensed physician, dentist, podiatrist, nurse practitioner, or physician assistant. The prescription must include site, modality, duration, and frequency of treatment. Total covered expenses for outpatient rehabilitative services is limited to a combined maximum of 30 visits per benefit year subject to preauthorization and concurrent review by PacificSource for medical necessity. Only treatment of neurologic conditions (e.g. stroke, spinal cord injury, head injury, pediatric neurodevelopmental problems, and other problems associated with pervasive developmental disorders for which rehabilitative services would be appropriate for children under 18 years of age) may be considered for additional benefits, not to exceed 30 visits per condition, when criteria for supplemental services are met. • Services for speech therapy will only be allowed when needed to correct stuttering, hearing loss, peripheral speech mechanism problems, and deficits due to neurological disease or injury. Speech and/or cognitive therapy for acute illnesses and injuries are covered up to one year post injury when the services do not duplicate those provided by other eligible providers, including occupational therapists or neuropsychologists. • Outpatient pulmonary rehabilitation programs are covered when prescribed by a physician for patients with severe chronic lung disease that interferes with normal daily activities despite optimal medication management. • For related provisions, see 'motion analysis', 'vocational rehabilitation', and 'speech therapy' under 'Excluded Services - Types of Treatments' in the Benefit Limitations and Exclusions section of this Summary Plan Description. • Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to the same payment amounts, conditions, and limitations that apply to similar expenses for illness, except that pregnancy is not considered a pre-existing condition. Please contact the PacificSource Customer Service Department as soon as you learn of your pregnancy. PacificSource's staff will explain your plan's maternity benefits and help you enroll in PacificSource's free prenatal care program. • Routine nursery care of a newborn while the mother is hospitalized and eligible for pregnancy- related benefits under this plan if the newborn is also eligible and enrolled in this plan. • Services of a licensed audiologist for medically necessary audiological (hearing) tests. • Services of a dentist or physician to treat injury of the jaw or natural teeth. Services must be provided within 18 months of the injury. Except for the initial examination, services for treatment of an injury to the jaw or natural teeth require preauthorization to be covered. • Services of a dentist or physician for orthognathic (jaw) surgery as follows: - When medically necessary to repair an accidental injury. Services must be provided within one year after the accident. - For removal of a malignancy, including reconstruction of the jaw within one year after that surgery SPD 0714_City of Ashland Parks Final 38 • Services of a board-certified or board-eligible genetic counselor when referred by a physician or nurse practitioner for evaluation of genetic disease • Medically necessary telemedical health services for health services covered by this plan when provided in person by a healthcare professional when the telemedical health service does not duplicate or supplant a health service that is available to the patient in person. The location of the patient receiving telemedical health services may include, but is not limited to: hospital; rural health clinic; federally qualified health center; physician's office; community mental health center; skilled nursing facility; renal dialysis center; or site where public health services are provided. Coverage of telemedical health services are subject to the same deductible, co-payment, or co-insurance requirements that apply to comparable health services provided in person. HOSPITAL AND SKILLED NURSING FACILITY SERVICES This plan covers medically necessary hospital inpatient services. Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation. Coverage includes eligible services provided by a hospital owned or operated by the state of Oregon, or any state approved mental health and developmental disabilities program. In addition to the hospital room, covered inpatient hospital services may include (but are not limited to): • Cardiac care unit • Operating room • Anesthesia and post-anesthesia recovery • Respiratory care • Inpatient medications • Lab and radiology services • Dressings, equipment, and other necessary supplies The plan does not cover charges for rental of telephones, radios, or televisions, or for guest meals or other personal items. Services of a skilled nursing facility and convalescent homes are covered for up to 120 days per benefit year when preauthorized by PacificSource. Services must be medically necessary. Confinement for custodial care is not covered. Inpatient rehabilitative services are covered up to a maximum of 50 days of rehabilitative care per benefit year, except that treatment for head or spinal cord injuries is covered for up to 60 days per benefit year. Recreation therapy is only covered as part of an inpatient rehabilitation admission. Services must be preauthorized by PacificSource OUTPATIENT SERVICES This plan covers the following outpatient care services: • Advanced diagnostic imaging procedures that are medically necessary for the diagnosis of illness or injury. For purposes of this benefit, advanced diagnostic imaging procedures include CT scans, MRIs, PET scans, CATH labs and nuclear cardiology studies. When services are provided as part of a covered emergency room visit, your plan's emergency room benefit applies. In all other situations and settings, benefits are subject to the deductibles, co-payments, and/or co-insurance stated in your Medical Benefit Summary for Outpatient Services - Advanced Diagnostic Imaging. • Diagnostic radiology and laboratory procedures provided or ordered by a physician, nurse practitioner, or physician assistant. These services may be performed or provided by laboratories, radiology facilities, hospitals, and physicians, including services in conjunction with office visits. • Benefits for members who are receiving services for end-stage renal disease (ESRD), who are eligible for Medicare, are limited to 125% of the current Medicare allowable amount for participating and nonparticipating ESRD service providers. Benefits will continue to be paid at the cost share level applied to other benefits in the same category for members who are not eligible for Medicare. SPD 0714_City of Ashland Parks Final 39 PacificSource will contact members when the first ESRD preauthorization request is received to assist the member in understanding their out-of-pocket expenses and care plan. • Emergency room services. The emergency room co-payment stated in your Medical Benefit Summary covers medical screening and any diagnostic tests needed for emergency care, such as radiology, laboratory work, CT scans, and MRIs. The co-payment does not cover further treatment provided on referral from the emergency room. In true medical emergencies, non-participating providers are paid at the participating provider level. Emergency room charges for services, supplies, or conditions excluded from coverage under this plan are not eligible for payment. Please see the Benefit Limitations and Exclusions section of this Summary Plan Description. • Surgery and other outpatient services. Benefits are based on the setting where services are performed. - For surgeries or outpatient services performed in a physician's office, the benefit stated in your Medical Benefit Summary for Professional Services - Office Procedures and Supplies applies. For surgeries or outpatient services performed in an ambulatory surgical center or outpatient hospital setting, both the benefits stated in your Medical Benefit Summary for Professional Services - Surgery and the Outpatient Services -Outpatient Surgery/Services apply- • Therapeutic radiology services, chemotherapy, and renal dialysis provided or ordered by a physician. Covered services include a prescribed, orally administered anticancer medication used to kill or slow the growth of cancerous cells. • Other medically necessary diagnostic services provided in a hospital or outpatient setting, including testing or observation to diagnose the extent of a medical condition. EMERGENCY SERVICES In a true medical emergency, this plan covers services and supplies necessary to determine the nature and extent of the emergency condition and to stabilize the patient. An emergency medical condition is an injury or sudden illness, including severe pain, so severe that a prudent layperson with an average knowledge of health and medicine would expect that failure to receive immediate medical attention would risk seriously damaging the health of a person or fetus in the case of a pregnant woman. Examples of emergency medical conditions include (but are not limited to): • Unusual or heavy bleeding • Sudden abdominal or chest pains Suspected heart attacks • Major traumatic injuries • Serious burns • Poisoning • Unconsciousness • Convulsions or seizures • Difficulty breathing • Sudden fevers If you need immediate assistance for a medical emergency, call 911. If you have an emergency medical condition, you should go directly to the nearest emergency room or appropriate facility. Care for a medical emergency is covered at the participating provider percentage stated in your Medical Benefit Summary even if you are treated at a non-participating hospital. If you are admitted to a non-participating hospital after your emergency condition is stabilized, your Plan Sponsor may require you to transfer to a participating facility in order to continue receiving benefits at the participating provider level. SPD 0714_City of Ashland Parks Final 40 Maternity Services Maternity means, in any one pregnancy, all prenatal services including complications and miscarriage, delivery, postnatal services provided within six months of delivery, and routine nursery care of a newborn child. Maternity services are covered subject to the deductible, co-payments, and/or co- insurance stated in your Medical Benefit Summary regardless of marital status. • Services of a physician or a licensed certified nurse midwife for pregnancy. Services are subject to the same payment amounts, conditions, and limitations that apply to similar expenses for illness. • Please contact the PacificSource Customer Service Department as soon as you learn of your pregnancy. PacificSource's staff will explain your plan's maternity benefits and help you enroll in PacificSource's free prenatal care program. • This plan provides routine nursery care of a newborn while the mother is hospitalized and eligible for pregnancy-related benefits under this plan if the newborn is also eligible and enrolled in this plan, regardless of marital status. Special Information about Childbirth - This plan covers hospital inpatient services for childbirth according to the Newborns' and Mothers' Health Protection Act of 1996. This plan does not restrict the length of stay for the mother or newborn child to less than 48 hours after vaginal delivery, or to less than 96 hours after Cesarean section delivery. Your provider is allowed to discharge you or your newborn sooner than that, but only if you both agree. For childbirth, your provider does not need to preauthorize your hospital stay with PacificSource. MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES This plan covers medically necessary crisis intervention, diagnosis, and treatment of mental health conditions and chemical dependency. Refer to the Benefit Limitations and Exclusions section of this Summary Plan Description for more information on services not covered by your plan. Mental Health and Chemical Dependency Services It is the intent of this plan to comply with all existing regulations of Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). If for some reason the information presented in the plan differs from the actual regulations of the MHPAEA, the plan reserves the right to administer the plan in accordance with such actual regulations. Providers Eligible for Reimbursement A mental and/or chemical healthcare provider (see Definitions section of this Summary Plan Description) is eligible for reimbursement if: • The mental and/or chemical healthcare provider is approved by the Oregon Department of Human Services; • The mental and/or chemical healthcare provider is accredited for the particular level of care for which reimbursement is being requested by the Oregon Joint Commission on Accreditation of Hospitals or the Commission on Accreditation of Rehabilitation Facilities; or • The patient is staying overnight at the mental and/or chemical healthcare facility (see Definitions section of this Summary Plan Description) and is involved in a structured program at least eight hours per day, five days per week; or • The mental and/or chemical healthcare provider is providing a covered benefit under this policy; and Eligible mental and/or chemical healthcare providers are: • A program licensed, approved, established, maintained, contracted with, or operated by the Addictions and Mental Health Division of the Oregon Health Authority; • A medical or osteopathic physician licensed by the State Board of Medical Examiners; • A psychologist (Ph.D.) licensed by the State Board of Psychologists' Examiners; • A nurse practitioner registered by the State Board of Nursing; • A clinical social worker (L.C.S.W.) licensed by the State Board of Clinical Social Workers; SPD 0714_City of Ashland Parks Final 41 • A Licensed Professional Counselor (L.P.C) licensed by the State Board of Licensed Professional Counselors and Therapists; • A Licensed Marriage and Family Therapist (L.M.F.T) licensed by the State Board of Licensed Professional Counselors and Therapists; and • A hospital or other healthcare facility licensed by the Joint Commission on Accreditation of Hospitals or the Commission on Accreditation of Rehabilitation Facilities for inpatient or residential care and treatment of mental health conditions and/or chemical dependency. Medical Necessity and Appropriateness of Treatment • As with all medical treatment, mental health and chemical dependency treatment is subject to review for medical necessity and/or appropriateness. Review of treatment may involve pre-service review, concurrent review of the continuation of treatment, post-treatment review, or a combination of these. PacificSource will notify the patient and patient's provider when a treatment review is necessary to make a determination of medical necessity. • A second opinion may be required for a medical necessity determination. PacificSource will notify the patient when this requirement is applicable. • PacificSource must be notified of an emergency admission within two business days. • Medication management by an M.D. (such as a psychiatrist) does not require review. • Treatment of substance abuse and related disorders is subject to placement criteria established by the American Society of Addiction Medicine. Mental Health Parity and Addiction Equity Act of 2008 This group health plan complies with all federal laws and regulations related to the Mental Health Parity and Addiction Equity Act of 2008. HOME HEALTH AND HOSPICE SERVICES • This plan covers home health services up to 180 visits per benefit year when preauthorized by PacificSource. Covered services include skilled nursing by a R.N. or L.P.N.; physical, occupational, and speech therapy; and medical social work services provided by a licensed home health agency. Private duty nursing is not covered. • Home infusion services are covered when preauthorized by PacificSource. This benefit covers parenteral nutrition, medications, and biologicals (other than immunizations) that cannot be self- administered. Benefits are paid at the percentage stated in your Medical Benefit Summary for home health care. • This plan covers hospice services when preauthorized by PacificSource. Hospice services are intended to meet the physical, emotional, and spiritual needs of the patient and family during the final stages of illness and dying, while maintaining the patient in the home setting. Services are intended to supplement the efforts of an unpaid caregiver. Hospice benefits do not cover services of a primary caregiver such as a relative or friend, or private duty nursing. PacificSource uses the following criteria to determine eligibility for hospice benefits: - The member's physician must certify that the member is terminally ill with a life expectancy of less than six months; - The member must be living at home; - A non-salaried primary caregiver must be available and willing to provide custodial care to the member on a daily basis; and - The member must not be undergoing treatment of the terminal illness other than for direct control of adverse symptoms. Only the following hospice services are covered: - Home nursing visits. - Home health aides when necessary to assist in personal care. - Home visits by a medical social worker. - Home visits by the hospice physician. - Prescription medications for the relief of symptoms manifested by the terminal illness. SPD 0714_City of Ashland Parks Final 42 - Medically necessary physical, occupational, and speech therapy provided in the home. - Home infusion therapy. - Durable medical equipment, oxygen, and medical supplies. Respite care provided in a nursing facility to provide relief for the primary caregiver, subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days. A member must be enrolled in a hospice program to be eligible for respite care benefits. - Inpatient hospice care when provided by a Medicare-certified or state-certified program when admission to an acute care hospital would otherwise be medically necessary. - Pastoral care and bereavement services. The member retains the right to all other services provided under this contract, including active treatment of non-terminal illnesses, except for services of another provider that duplicate the services of the hospice team. DURABLE MEDICAL EQUIPMENT • This plan covers prosthetic and orthotic devices that are medically necessary to restore or maintain the ability to complete activities of daily living or essential job-related activities and that are not solely for comfort or convenience. Benefits include coverage of all services and supplies medically necessary for the effective use of a prosthetic or orthotic device, including formulating its design, fabrication, material and component selection, measurements, fittings, static and dynamic alignments, and instructing the patient in the use of the device. Benefits also include coverage for any repair or replacement of a prosthetic or orthotic device that is determined medically necessary to restore or maintain the ability to complete activities of daily living or essential job-related activities and that is not solely for comfort or convenience. • This plan covers durable medical equipment prescribed exclusively to treat medical conditions. Covered equipment includes crutches, wheelchairs, orthopedic braces, home glucose meters, equipment for administering oxygen, and non-power assisted prosthetic limbs and eyes. Durable medical equipment must be prescribed by a licensed M.D., D.O., N.P., P.A., D.D.S., D.M.D., or D.P.M. to be covered. This plan does not cover equipment commonly used for nonmedical purposes, for physical or occupational therapy, or prescribed primarily for comfort. Please see 'Excluded Services - Equipment and Devices' in the Benefit Limitations and Exclusions section for information on items not covered. The following limitations apply to durable medical equipment: - This benefit covers the cost of either purchase or rental of the equipment for the period needed, whichever is less. Repair or replacement of equipment is also covered when necessary, subject to all conditions and limitations of the plan. If the cost of the purchase, rental, repair, or replacement is over $800, preauthorization by PacificSource is required. - Only expenses for durable medical equipment, or prosthetic and orthotic devices that are provided by a PacificSource contracted provider or a provider that satisfies the criteria of the Medicare fee schedule for Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description are eligible for reimbursement. Mail order or Internet/Web based providers are not eligible providers. - Purchase, rental, repair, lease, or replacement of a power-assisted wheelchair (including batteries and other accessories) requires preauthorization by PacificSource and is payable only in lieu of benefits for a manual wheelchair. The durable medical equipment benefit also covers lenses to correct a specific vision defect resulting from a severe medical or surgical problem, such as stroke, neurological disease, trauma, or eye surgery other than refraction procedures. Coverage is subject to the following limitations: o The medical or surgical problem must cause visual impairment or disability due to loss of binocular vision or visual field defects (not merely a refractive error or astigmatism) that requires lenses to restore some normalcy to vision. o The maximum allowance for glasses (lenses and frames), or contact lenses in lieu of glasses, is limited to $200 per initial case. 'Initial case' is defined as the first time surgery or treatment is performed on either eye. Other policy limitations, such as exclusions for extra lenses, other hardware, tinting of lenses, eye exercises, or vision therapy, also apply. SPD 0714_City of Ashland Parks Final 43 o Benefits for subsequent medically necessary vision corrections to either eye (including an eye not previously treated) are limited to the cost of lenses only. Reimbursement is subject to the deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable medical equipment and is in lieu of, and not in addition to benefits payable under any vision endorsement that may be added to this plan. The durable medical equipment benefit also covers hearing aids for members under 18 years of age and younger, or 25 years of age and younger if the member is enrolled in a secondary school or an accredited educational institution. Coverage is limited to a maximum benefit of $4,000 every 48 months. The benefit amount may be adjusted on January 1 of each year to reflect the U.S City Average Consumer Price Index. Medically necessary treatment for sleep apnea and other sleeping disorders is covered when preauthorized by PacificSource. Coverage of oral devices includes charges for consultation, fitting, adjustment, follow-up care, and the appliance. The appliance must be prescribed by a physician specializing in evaluation and treatment of obstructive sleep apnea, and the condition must meet criteria for obstructive sleep apnea. Wigs following chemotherapy or radiation therapy are covered up to a maximum benefit of $150 per benefit year. Breastfeeding pumps, manual and electric, are covered at no cost per pregnancy when purchased or rented from a licensed provider, or purchased from a retail outlet. Hospital- grade breast pumps are excluded under preventive care and regular benefits. TRANSPLANT SERVICES This plan covers certain medically necessary organ and tissue transplants. It also covers the cost of acquiring organs or tissues needed for covered transplants and limited travel expenses for the patient, subject to certain limitations. All pre-transplant evaluations, services, treatments, and supplies for transplant procedures require preauthorization by PacificSource. You must have been covered under this plan for at least 24 consecutive months or since birth to be eligible for transplant benefits, including benefits for transplantation evaluation. See Exclusion Periods - Transplants in the Benefit Limitations and Exclusions section of this Summary Plan Description for details. This plan covers the following medically necessary organ and tissue transplants: • Kidney • Kidney - Pancreas • Pancreas whole organ transplantation (under certain criteria) • Heart • Heart - Lung • Lung • Liver (under certain criteria) • Bone marrow and peripheral blood stem cell • Pediatric bowel This plan only covers transplants of human body organs and tissues. Transplants of artificial, animal, or other non-human organs and tissues are not covered. Expenses for the acquisition of organs or tissues for transplantation are covered only when the transplantation itself is covered under this contract, and is subject to the following limitations: • Testing of related or unrelated donors for a potential living related organ donation is payable at the same percentage that would apply to the same testing of an insured recipient. • Expense for acquisition of cadaver organs is covered, payable at the same percentage and subject to the same maximum dollar limitation, if any, as the transplant itself. SPD 0714_City of Ashland Parks Final 44 • Medical services required for the removal and transportation of organs or tissues from living donors are covered. Coverage of the organ or tissue donation is at the same percentage payable for the transplant itself up to $8,000 if the donor is a member of this plan, and applies to the maximum dollar limitation for the transplant, if any. - If the donor is not a PacificSource member, only those complications of the donation that occur during the initial hospitalization are covered up to $8,000, and such complications are covered only to the extent that they are not covered by another health plan or government program. Coverage is at the same percentage payable for the transplant itself, and also applies to the maximum dollar limitation, if any, for the transplant. If the donor is a PacificSource member, complications of the donation are covered as any other illness would be covered, up to $8,000 (as outlined above). • Transplant related services, including HLA typing, sibling tissue typing, and evaluation costs, are considered transplant expenses and accumulate toward any transplant benefit limitations and are subject to PacificSource's provider contractual agreements (see Payment of Transplant Benefits, below). Travel and housing expenses for the recipient are limited to $5,000 per transplant. Travel and living expenses are not covered for the donor. Payment of Transplant Benefits If a transplant is performed at a participating Center of Excellence transplantation facility, covered charges of the facility are subject to plan deductibles (co-insurance and co-payment amounts after deductible are waived). If PacificSource's contract with the facility includes the services of the medical professionals performing the transplant (such as physicians, nurses, and anesthesiologists), those charges are also subject to plan deductibles (co-insurance and co-payment amounts after deductible are waived). If the professional fees are not included in PacificSource's contract with the facility, then those benefits are provided according to your Medical Benefit Summary. If transplant services are available through a contracted transplantation facility but are not performed at a contracted facility, you are responsible for satisfying any deductibles or co-payments stated in your Medical Benefit Summary. This plan then pays at of 60% of the UCR after deductible and co-payments. Services of non-participating medical professionals are paid at the non-participating provider benefit level percentages and do not apply to the out-of-pocket maximum. OTHER COVERED SERVICES, SUPPLIES, AND TREATMENTS • This plan covers services of a state certified ground or air ambulance when private transportation is medically inappropriate because the acute medical condition requires paramedic support. Benefits are provided for emergency ambulance service and/or transport to the nearest facility capable of treating the condition. Air ambulance service is covered only when ground transportation is medically or physically inappropriate. Reimbursement to nonparticipating air ambulance services are based on 125% of the Medicare allowance. In some cases Medicare allowance may be significantly lower than the provider's billed amount. The provider may hold you responsible for the amount they bill in excess of the Medicare allowance, as well as applicable deductibles and co- insurance. Medically necessary travel, other than transportation by a licensed ambulance service, to the nearest facility qualified to treat the patient's medical condition is covered when approved in advance by PacificSource. • This plan covers biofeedback to treat migraine headaches or urinary incontinence when provided by an otherwise eligible practitioner. • This plan covers blood transfusions, including the cost of blood or blood plasma. • This plan covers removal, repair, or replacement of an internal breast prosthesis due to a contracture or rupture, but only when the original prosthesis was for a medically necessary mastectomy. Preauthorization by PacificSource is required, and eligibility for benefits is subject to the following criteria: - The contracture or rupture must be clinically evident by a physician's physical examination, imaging studies, or findings at surgery. - This plan covers removal, repair, and/or replacement of the prosthesis; a new reconstruction is not covered. SPD 0714_City of Ashland Parks Final 45 - Removal, repair, and/or replacement of the prosthesis is not covered when recommended due to an autoimmune disease, connective tissue disease, arthritis, allergenic syndrome, psychiatric syndrome, fatigue, or other systemic signs or symptoms. - PacificSource may require a signed loan receipt/subrogation agreement before providing coverage for this benefit. • This plan covers breast reconstruction in connection with a medically necessary mastectomy. Coverage is provided in a manner determined in consultation with the attending physician and patient for: - All stages of reconstruction of the breast on which the mastectomy was performed; - Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema Benefits for breast reconstruction are subject to all terms and provisions of the plan, including deductibles, co-payments and/or co-insurance stated in your Medical Benefit Summary. • This plan covers cardiac rehabilitation as follows: - Phase I (inpatient) services are covered under inpatient hospital benefits. - Phase II (short-term outpatient) services are covered subject to the deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for outpatient hospital benefits. Benefits are limited to services provided in connection with a cardiac rehabilitation exercise program that does not exceed 36 sessions and that are considered reasonable and necessary. - Phase III (long-term outpatient) services are not covered. • This plan covers IUD, diaphragm, Norplant and cervical cap contraceptive devices along with their insertion or removal. Contraceptive devices that can be obtained over the counter or without a prescription, such as condoms are not covered. • This plan covers corneal transplants. Preauthorization is not required. • In the following situations, this plan covers one attempt at cosmetic or reconstructive surgery: - When necessary to correct a functional disorder; or - When necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or - When necessary to correct a scar or defect on the head or neck that resulted from a covered surgery. Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred. Preauthorization by PacificSource is required for all cosmetic and reconstructive surgeries covered by this plan. For information on breast reconstruction, see `breast prosthesis' and 'breast reconstruction' in this section. • This plan covers dental and orthodontic services for the treatment of craniofacial anomalies when medically necessary to restore function. Coverage includes but is not limited to physical disorders identifiable at birth that affect the bony structures of the face or head, such as cleft palate, cleft lip, craniosynostosis, craniofacial microsomia and Treacher Collins syndrome. Coverage is limited to the least costly clinically appropriate treatment. Cosmetic procedures and procedures to improve on the normal range of functions are not covered. See the exclusions for cosmetic/reconstructive services, dental examinations and treatment, jaw surgery, and orthognathic surgery under the `Excluded Services' section • This plan provides coverage for certain diabetic supplies and training as follows: Diabetic supplies other than insulin and syringes (such as lancets, test strips, and glucostix) are covered subject to the deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable medical equipment. You may purchase those supplies from any retail outlet and send your receipts to PacificSource, along with your name, group number, and member ID number. PacificSource will process the claim and mail you a reimbursement check. SPD 0714_City of Ashland Parks Final 46 Diabetic insulin and syringes are covered under your prescription drug benefit, if your plan includes prescription coverage. Lancets and test strips are also available under that prescription benefit in lieu of those covered supplies under the medical plan. This plan covers one diabetes self-management education program at the time of diagnosis, and up to three hours of education per year if there is a significant change in your condition or its treatment. To be covered, the training must be provided by an accredited diabetes education program, or by a physician, registered nurse, nurse practitioner, certified diabetes educator, or licensed dietitian with expertise in diabetes. This plan covers medically necessary telemedical health services provided in connection with the treatment of diabetes (see Professional Services in this section). • This plan covers dietary or nutritional counseling provided by a registered dietitian under certain circumstances. It is covered under the diabetic education benefit, or for management of inborn errors of metabolism (excluding obesity), or for management of anorexia nervosa or bulimia nervosa (to a lifetime maximum of five visits). • This plan covers nonprescription elemental enteral formula ordered by a physician for home use. Formula is covered when medically necessary to treat severe intestinal malabsorption and the formula comprises a predominant or essential source of nutrition. Coverage is subject to the deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable medical equipment. • This plan covers routine foot care for patients with diabetes mellitus. • Hospitalization for dental procedures is covered when the patient has another serious medical condition that may complicate the dental procedure, such as serious blood disease, unstable diabetes, or severe cardiovascular disease, or the patient is physically or developmentally disabled with a dental condition that cannot be safely and effectively treated in a dental office. Coverage requires preauthorization by PacificSource, and only charges for the facility, anesthesiologist, and assistant physician are covered. Hospitalization because of the patient's apprehension or convenience is not covered. • This plan covers treatment for inborn errors of metabolism involving amino acid, carbohydrate, and fat metabolism for which widely accepted standards of care exist for diagnosis, treatment, and monitoring exist, including quantification of metabolites in blood, urine or spinal fluid or enzyme or DNA confirmation in tissues. Coverage includes expenses for diagnosing, monitoring and controlling the disorders by nutritional and medical assessment, including but not limited to clinical visits, biochemical analysis and medical foods used in the treatment of such disorders. Nutritional supplies are covered subject to the deductible, co-payment, and/or co-insurance stated in your Medical Benefit Summary for durable medical equipment. • Injectable drugs and biologicals administered by a physician are covered when medically necessary for diagnosis or treatment of illness or injury. This benefit does not include immunizations (see Preventive Care Services in this section) or drugs or biologicals that can be self-administered or are dispensed to a patient. • This plan covers maxillofacial prosthetic services when prescribed by a physician as necessary to restore and manage head and facial structures. Coverage is provided only when head and facial structures cannot be replaced with living tissue, and are defective because of disease, trauma, or birth and developmental deformities. To be covered, treatment must be necessary to control or eliminate pain or infection or to restore functions such as speech, swallowing, or chewing. Coverage is limited to the least costly clinically appropriate treatment, as determined by the physician. Cosmetic procedures and procedures to improve on the normal range of functions are not covered. Dentures, prosthetic devices for treatment of TMJ conditions, and artificial larynx are also not covered. • Pediatric dental care is not covered. • The routine costs of care associated with approved clinical trials are covered. Benefits are only provided for routine costs of care associated with approved clinical trials. Expenses for services or supplies that are not considered routine costs of care are not covered. For more information, see 'routine costs of care' in the Definitions section of this Summary Plan Description. A 'qualified individual' is someone who is eligible to participate in a qualifying clinical trial. If a participating provider is participating in an approved clinical trial, the qualified individual may be required to participate in the trial through that participating provider if the provider will accept the individual as a participant in the trial. SPD 0714_City of Ashland Parks Final 47 • Sleep studies are covered when ordered by a pulmonologist, neurologist, otolaryngologist, or certified sleep medicine specialist, and when performed at a certified sleep laboratory. • This plan covers medically necessary therapy and services for the treatment of traumatic brain injury. • This plan covers tubal ligation and vasectomy procedures with no waiting period. BENEFIT LIMITATIONS AND EXCLUSIONS Least Costly Setting for Services Covered services must be performed in the least costly setting where they can be provided safely. If a procedure can be done safely in an outpatient setting but is performed in a hospital inpatient setting, this plan will only pay what it would have paid for the procedure on an outpatient basis. If services are performed in an inappropriate setting, your benefits can be reduced by up to 30 percent or $2,500, whichever is less. EXCLUDED SERVICES A Note About Optional Benefits If your Plan Sponsor provides coverage for optional benefits such as prescription drugs, vision services, chiropractic care, or alternative care, you'll find those Member Benefit Summaries in this Summary Plan Description. If your Plan Sponsor provides optional benefits for an exclusion listed below, then the exclusion does not apply to the extent that coverage exists under the optional benefit. For example, if your Plan Sponsor provides optional chiropractic coverage, then the exclusion for chiropractic care listed below under `Types of Treatment' does not apply to you. Types of Treatment - This plan does not cover the following: • Acupuncture • Chelation therapy including associated infusions of vitamins and/or minerals, except as medically necessary for the treatment of selected medical conditions and medically significant heavy metal toxicities • Day care or custodial care - Care and related services designed essentially to assist a person in maintaining activities of daily living, e.g. services to assist with walking, getting in/out of bed, bathing, dressing, feeding, preparation of meals, homemaker services, special diets, rest cures, day care, and diapers. Custodial care is only covered in conjunction with respite care allowed under this plan's hospice benefit. For related provisions, see 'Hospital and Skilled Nursing Facility Services' and 'Home Health and Hospice Services' in the Covered Expenses section of this Summary Plan Description. • Dental examinations and treatment, which means any services or supplies to prevent, diagnose, or treat diseases of the teeth and supporting tissues or structures, except as specified in Covered Expenses - Preventive Care Services except as specifically provided with a separate PacificSource Dental Plan (See the Dental Benefit Plan section of this Summary Plan Description). • Eye exercises, therapy, and procedures - Orthoptics, vision therapy, and procedures intended to correct refractive errors • Fitness or exercise programs and health or fitness club memberships • Foot care (routine) - Services and supplies for corns and calluses of the feet, conditions of the toenails other than infection, hypertrophy or hyperplasia of the skin of the feet, and other routine foot care, except in the case of patients being treated for diabetes mellitus • Genetic (DNA) testing, except for tests identified as medically necessary for the diagnosis and standard treatment of specific diseases • Homeopathic treatment • Infertility - Services and supplies, surgery, treatment, or prescriptions to prevent, or cure infertility or to induce fertility (including Gamete and/or Zygote Interfallopian Transfer; i.e. GIFT or ZIFT), except for medically necessary medication to preserve fertility during treatment with cytotoxic chemotherapy. For related provisions, see the exclusion for 'family planning' in this section. For purposes of this plan, infertility is defined as: SPD 0714_City of Ashland Parks Final 48 o Male: Low sperm counts or the inability to fertilize an egg o Female: The inability to conceive or carry a pregnancy to 12 weeks • Instructional or educational programs, except diabetes self-management programs • Jaw - Services or supplies for developmental or degenerative abnormalities of the jaw, malocclusion, dental implants, or improving placement of dentures. • Massage, massage therapy, or neuromuscular re-education, even as part of a physical therapy program • Motion analysis, including videotaping and 3-D kinematics, dynamic surface and fine wire electromyography, and physician review • Myeloablative high dose chemotherapy, except when the related transplant is specifically covered under the transplantation provisions of this plan. For related provisions, see 'Transplant Services' in the Covered Expenses section of this Summary Plan Description. • Naturopathic treatment • Obesity or weight control - Surgery or other related services or supplies provided for weight control or obesity (including all categories of obesity) except as listed under 'Preventive Care Services', whether or not there are other medical conditions related to or caused by obesity. This also includes services or supplies used for weight loss, such as food supplementation programs and behavior modification programs, regardless of the medical conditions that may be caused or exacerbated by excess weight, and self-help or training programs for weight control. Obesity screening and counseling are covered for children and adults; see the 'dietary or nutritional counseling' section under 'Other Covered Services'. • Oral/facial motor therapy for strengthening and coordination of speech-producing musculature and structures • Osteopathic manipulation, except for treatment of disorders of the musculoskeletal system • Physical or eye examinations required for administrative purposes such as participation in athletics, admission to school, or by a Plan Sponsor • Private nursing service • Programs that teach a person to use medical equipment, care for family members, or self- administer drugs or nutrition (except for diabetic education benefit) • Rehabilitation - Functional capacity evaluations, work hardening programs, vocational rehabilitation, community reintegration services, and driving evaluations and training programs • Routine services and supplies - Services, supplies, and equipment not involved in diagnosis or treatment but provided primarily for the comfort, convenience, cosmetic purpose, environmental control, or education of a patient or for the processing of records or claims. These include but are not limited to: o Missed appointments, completion of claim forms, or reports requested by PacificSource in order to process claims o Appliances, such as air conditioners, humidifiers, air filters, whirlpools, hot tubs, heat lamps, or tanning lights o Private nursing services or personal items such as telephones, televisions, and guest meals in a hospital or skilled nursing facility o Maintenance supplies and equipment not unique to medical care • Screening tests - Services and supplies, including imaging and screening exams performed for the sole purpose of screening and not associated with specific diagnoses and/or signs and symptoms of disease or of abnormalities on prior testing (including but not limited to total body CT imaging, CT colonography and bone density testing).This does not include preventive care screenings listed under 'Preventive Care Services' in the Covered Expenses section of this Summary Plan Description. • Self-help or training programs • Sexual disorders - Services or supplies for the treatment of sexual dysfunction or inadequacy unless medically necessary to treat a mental health issue and diagnosis. For related provisions, see the exclusions for 'family planning', 'infertility', and 'mental illness' in this section. SPD 0714_City of Ashland Parks Final 49 • Snoring - Services or supplies for the diagnosis or treatment of snoring or upper airway resistance disorders, including somnoplasty • Speech therapy - Oral/facial motor therapy for strengthening and coordination of speech-producing muscles and structures, except as medically necessary in the restoration or improvement of speech following a traumatic brain injury or for a child 17 years of age or younger diagnosed with a pervasive developmental disorder. • Temporomandibular joint (TMJ)-related services, or treatment for associated myofascial pain, including physical or oromyofacial therapy Surgeries and Procedures - This plan does not cover the following: • Abdominoplasty for any indication • Artificial insemination, in vitro fertilization, or GIFT procedures • Cosmetic/reconstructive services and supplies - Except as specified in the Covered Expenses - Other Covered Services, Supplies, and Treatments section of this Summary Plan Description, services and supplies, including drugs, rendered primarily for cosmetic/reconstructive purposes and any complications as a result of non-covered cosmetic/reconstructive surgery. Cosmetic/reconstructive services and supplies are those performed primarily to improve the body's appearance and not primarily to restore impaired function of the body, regardless of whether the area to be treated is normal or abnormal. • Electronic Beam Tomography (EBT) • Eye refraction procedures, orthoptics, vision therapy, or other services to correct refractive error except as indicated in the Covered Services section of this Summary Plan Description • Jaw surgery - Treatment for abnormalities of the jaw, malocclusion, or improving the placement of dentures and dental implants • Orthognathic surgery - Services and supplies to augment or reduce the upper or lower jaw, except as specified under 'Professional Services' in the Covered Expenses section of this Summary Plan Description. • Panniculectomy for any indication • Sex reassignment - Procedures, services or supplies related to a sex reassignment unless medically necessary. For related provisions, see exclusions for 'mental illness' in this section. o Excluded procedures include, but are not limited to: staged gender reassignment surgery, including breast augmentation; penile implantation; liposuction, thyroid chondroplasty, laryngoplasty, or shortening of the vocal cords, and/or hair removal specifically to assist the appearance of other characteristics of gender reassignment. • Surgery to reverse voluntary sterilization • Transplants - Any services, treatments, or supplies for the transplantation of bone marrow or peripheral blood stem cells or any human body organ or tissue, except as expressly provided under the provisions of this plan for covered transplantation expenses. For related provisions see 'Transplant Services' in the Covered Expenses section of this Summary Plan Description. Mental Health Services - This plan does not cover the following services, whether provided by a mental health or chemical dependency specialist or by any other provider: Treatment for the following diagnosis: • Diagnostic codes V 15.81 through V71.09 (DSM-IV-TR, Forth Edition) except V61.20, V61.21, and V62.82 when used with children five years of age or younger • Food dependencies • Gender Identity Disorders in Adults (GID) • Learning disorders • Mental illness does not include -Treatment of intellectual disabilities and relationship problems (e.g. parent-child, partner, sibling, or other relationship issues), except the treatment of children five years of age or younger for parent-child relational problems, physical abuse of a child, sexual abuse of a child, neglect of a child, or bereavement. This plan does not cover educational or SPD 0714_City of Ashland Parks Final 50 correctional services or sheltered living provided by a school or halfway house, except outpatient services received while temporarily living in a shelter; psychoanalysis or psychotherapy received as part of an educational or training program, regardless of diagnosis or symptoms that may be present; or a court-ordered sex offender treatment program. The following treatment types are also excluded, regardless of diagnosis: marital/partner counseling; support groups; sensory integration training; biofeedback except to treat migraine headaches or urinary incontinence; hypnotherapy; academic skills training; narcosynthesis; aversion therapy; and social skill training. Recreation therapy is only covered as part of an inpatient or residential admission. The following are also excluded: court-mandated diversion and/or chemical dependency education classes; court-mandated psychological evaluations for child custody determinations; voluntary mutual support groups such as Alcoholics Anonymous; adolescent wilderness treatment programs; mental examinations for the purpose of adjudication of legal rights; psychological testing and evaluations not provided as an adjunct to treatment or diagnosis of a stress management, parenting skills, or family education; assertiveness training; image therapy; sensory movement group therapy; marathon group therapy; sensitivity training; and psychological evaluation for sexual dysfunction or inadequacy. • Mental retardation • Nicotine related disorders • Paraphilias Treatment programs, training, or therapy as follows: • Academic skills training • Aversion therapy • Biofeedback (other than as specifically noted under the Covered Expenses - Other covered Services, Supplies, and Treatment section) • Court-ordered sex offender treatment programs • Educational or correctional services or sheltered living provided by a school or halfway house • Equine/animal therapy • Hypnotherapy • Narcosynthesis • Psychoanalysis or psychotherapy received as part of an educational or training program, regardless of diagnosis or symptoms that may be present • Marital/partner counseling • Recreation therapy outside a inpatient or residential treatment setting • Sensory integration training • Social skill training • Support groups Drugs and Medications - This plan does not cover the following: • Drugs and biologicals that can be self-administered (including injectibles), other than those provided in a hospital emergency room, or other institutional setting, or as outpatient chemotherapy and dialysis, which are covered • Growth hormone injections or treatments, except to treat documented growth hormone deficiencies • Immunizations when recommended for or in anticipation of exposure through travel or work • Over-the-counter medications or non-prescription drugs Equipment and Devices - This plan does not cover the following: • Computer or electronic equipment for monitoring asthmatic, diabetic, or similar medical conditions or related data • Equipment commonly used for nonmedical purposes - This plan does not cover the following: SPD 0714_City of Ashland Parks Final 51 o Equipment commonly used for nonmedical purposes, or marketed to the general public, or intended to alter the physical environment. This includes appliances like adjustable power beds sold as furniture, air conditioners, air purifiers, room humidifiers, heating and cooling pads, home blood pressure monitoring equipment, light boxes, conveyances other than conventional wheelchairs, whirlpool baths, spas, saunas, heat lamps, tanning lights, and pillows. It also includes orthopedic shoes and shoe modifications. Mattresses and mattress pads are only covered when medically necessary to heal pressure sores. • Equipment used primarily in athletic or recreational activities. This includes exercise equipment for stretching, conditioning, strengthening, or relief of musculoskeletal problems • Modifications to vehicles or structures to prevent, treat, or accommodate a medical condition • Personal items such as telephones, televisions, and guest meals during a stay at a hospital or other inpatient facility • Replacement costs for worn or damaged durable medical equipment that would otherwise be replaceable without charges under warranty or other agreement Experimental or Investigational Treatment Your Plan Sponsor's plan does not cover experimental or investigational treatment. By that, PacificSource means services, supplies, protocols, procedures, devices, chemotherapy, drugs or medicines or the use thereof that are experimental or investigational for the diagnosis and treatment of the patient. It includes treatment that, when and for the purpose rendered: • Has not yet received full U.S. government agency approval (e.g. FDA) for other than experimental, investigational, or clinical testing; • Is not of generally accepted medical practice in Oregon or as determined by PacificSource in consultation with medical advisors, medical associations, and/or technology resources; • Is not approved for reimbursement by the Centers for Medicare and Medicaid Services; • Is furnished in connection with medical or other research; or • Is considered by any governmental agency or subdivision to be experimental or investigational, not reasonable and necessary, or any similar finding. An experimental or investigational service is not made eligible for benefits by the fact that other treatment is considered by your healthcare provider to be ineffective or not as effective as the service or that the service is prescribed as the most likely to prolong life. When making benefit determinations about whether treatments are investigational or experimental, PacificSource relies on the above resources as well as: • Expert opinions of specialists and other medical authorities; • Published articles in peer-reviewed medical literature; • External agencies whose role is the evaluation of new technologies and drugs; and • External review by an independent review organization. The following will be considered in making the determination whether the service is in an experimental and/or investigational status: • Whether there is sufficient evidence to permit conclusions concerning the effect of the services on health outcomes; • Whether the scientific evidence demonstrates that the services improve health outcomes as much or more than established alternatives; • Whether the scientific evidence demonstrates that the services' beneficial effects outweigh any harmful effects; and • Whether any improved health outcomes from the services are attainable outside an investigational setting. If you or your provider have any concerns about whether a course of treatment will be covered, PacificSource encourages you to contact PacificSource's Customer Service Department. PacificSource will arrange for medical review of your case against PacificSource's criteria, and notify you of whether the proposed treatment will be covered. SPD 0714_City of Ashland Parks Final 52 Other Items - This plan does not cover the following: • Treatment not medically necessary - Services or supplies that are not medically necessary for the diagnosis or treatment of an illness, injury, or disease. For related provisions, see `medically necessary' in the Definitions section and `Understanding Medical Necessity' in the Covered Expenses section of this Summary Plan Description. • Treatment prior to enrollment - Services or supplies a member received prior to enrolling in coverage provided by this plan; charges for inpatient stays that begin before you were covered by this plan; services or supplies received before this plan's coverage began; admission prior to coverage; services and supplies for an admission to a hospital, skilled nursing facility or specialized facility that began before the patient's coverage under this plan • Treatment after coverage ends - Services or supplies received after enrollment in this policy ends. (The only exception is if this policy is replaced by another group health policy while you are hospitalized. The plan will continue paying covered hospital expenses until you are released or your benefits are exhausted, whichever occurs first.) • Care and related services designed essentially to assist a person in maintaining activities of daily living, e.g. services to assist with walking, getting in/out of bed, bathing, dressing, feeding, and preparation of meals, homemaker services, special diets, rest crew, day care, and diapers. Custodial care is only covered in conjunction with respite care allowed under this policy's hospice benefit (see Covered Expenses - Hospital, Skilled Nursing Facility, Home Health, and Hospice Services). • Services or supplies available to you from another source, including those available through a government agency • Services or supplies for which no charge is made, for which the member is not legally required to pay, or for which a provider or facility is not licensed to provide even though the service or supply may otherwise be eligible. This exclusion includes services provided by the member, or by an immediate family member. • Services or supplies for which you are not willing to release the medical or eligibility information PacificSource needs to determine the benefits paid under this plan • Charges that are the responsibility of a third party who may have caused the illness, injury, or disease or other insurers covering the incident (such as workers' compensation insurers, automobile insurers, and general liability insurers) • Charges over the usual, customary, and reasonable fee (UCR) - Any amount in excess of the UCR for a given service or supply, except alternative care. • Treatment of any illness, injury, or disease resulting from an illegal occupation or attempted felony, or treatment received while in the custody of any law enforcement authority • Treatment of any condition caused by a war, armed invasion, or act of aggression, or while serving in the armed forces • Treatment of any work-related illness or injury, unless you are the owner, partner, or principal of the Plan Sponsor, injured in the course of employment of the Plan Sponsor, and are otherwise exempt from, and not covered by, state or federal workers' compensation insurance. This includes illness or injury caused by any for-profit activity, whether through employment or self-employment. • Treatment while incarcerated - Services or supplies a member receives while in the custody of any state or federal law enforcement authorities or while in jail or prison • Charges for phone consultations, missed appointments, get acquainted visits, completion of claim forms, or reports PacificSource needs to process claims • Any amounts in excess of the allowable fee for a given service or supply • Training or self-help programs - General fitness exercise programs, and programs that teach a person how to use durable medical equipment or care for a family member. Also excluded are health or fitness club services or memberships and instruction programs, including but not limited to those to learn to self-administer drugs or nutrition, except as specifically provided for in this plan. • Services of providers who are not eligible for reimbursement under this plan. An individual organization, facility, or program is not eligible for reimbursement for services or supplies, regardless of whether this plan includes benefits for such services or supplies, unless the individual, organization, facility, or program is licensed by the state in which services are provided SPD 0714_City of Ashland Parks Final 53 as an independent practitioner, hospital, ambulatory surgical center, skilled nursing facility, durable medical equipment supplier, or mental and/or chemical healthcare facility. And to the extent PacificSource maintains credentialing requirements the practitioner or facility must satisfy those requirements in order to be considered an eligible provider. • Scheduled and/or non-emergent medical care outside of the United States. • Services otherwise available - These include but are not limited to: o Services or supplies for which payment could be obtained in whole or in part if the member applied for payment under any city, county, state (except Medicaid), or federal law; and o Services or supplies the member could have received in a hospital or program operated by a federal government agency or authority, except otherwise covered expenses for services or supplies furnished to a member by the Veterans' Administration of the United States that are not military service-related. This exclusion does not apply to covered services provided through Medicaid or by any hospital owned or operated by the State of Oregon or any state-approved community mental health and developmental disability program. • Benefits not stated - Services and supplies not specifically described as benefits under the group health policy and/or any endorsement attached hereto EXCLUSION PERIODS Exclusion Period for Transplant Benefits Except for corneal transplants, organ and tissue transplants are not covered until you have been enrolled in this plan for 24 months or since birth. If you were covered under another health insurance plan before enrolling in this plan, you can receive credit for your prior coverage. See the Credit for Prior Coverage section, below. CREDIT FOR PRIOR COVERAGE You can receive credit toward this plan's exclusion periods if you had qualifying healthcare coverage before enrolling in this plan. To qualify for this credit, there may not have been more than a 63-day gap between your last day of coverage under the previous health plan and your first day of coverage (or the first day of your Plan Sponsor's probationary waiting period) under this plan. Your prior coverage must have been a group health plan, COBRA or state continuation coverage, individual health policy (including student plans), Medicare, Medicaid, TRICARE, State Children's Health Insurance Program, and coverage through high risk pools and the Peace Corps. If you were covered as a dependent under a plan that meets these qualifications, you will qualify for credit. Many people elect the COBRA or state continuation coverage available under a prior plan to make sure they won't have more than a 63-day gap in coverage. It is your responsibility to show you had creditable coverage. If you qualify for credit, PacificSource will count every day of coverage under your prior plan toward this plan's exclusion periods for pre- existing conditions, other specified conditions, and transplants (explained above). Evidence of Prior Creditable Coverage You can show evidence of creditable coverage by sending PacificSource a Certificate of Creditable Coverage from your previous health plan. All health plans, insurance companies, and HMOs are required by law to provide these certificates on request. Most insurers issue these certificates automatically whenever someone's coverage ends. The certificate shows how long you were covered under your previous plan and when your coverage ended. If you do not have a certificate of prior coverage, contact your previous insurance company or Plan Sponsor (such as your former employer, if you had a group health plan). You have the right to request a certificate from any prior plan, insurer, HMO, or other entity through which you had creditable coverage. If you are unable to obtain a certificate, contact PacificSource's Membership Services Department for assistance. SPD 0714_City of Ashland Parks Final 54 HEALTH CARE MANAGEMENT AND PREAUTHORIZATION What is Health Care Management Your Plan Sponsor desires to provide you and your family with a heath care benefit plan that financially protects you from significant health care expenses and assures you quality care. While part of increasing health care costs results from new technology and important medical advances, another significant cause is the way health care services are used. Some studies indicate that a high percentage of the cost for health care services may be unnecessary. For example, hospital stays may be longer than necessary. Some hospitalizations may be entirely avoidable, such as when surgery could be performed at an outpatient facility with equal quality and safety. Also, surgery is sometimes performed when other treatment could be more effective. All of these instances increase costs for you and the plan. Your Plan Sponsor has contracted with PacificSource to assist you in determining whether or not proposed services are appropriate for reimbursement under this plan. The program is not intended to diagnose or treat medical conditions, dictate a treatment plan, guarantee benefits, or validate eligibility. The medical professionals who conduct the program focus their review on the appropriateness for reimbursement of hospital stays and proposed surgical procedures. Required Admission Review - You are required to call PacificSource's toll-free number, (888) 977- 9299, prior to any elective inpatient stay or any scheduled surgical procedure. In most cases, your medical provider will make the call for you. You must also call within 48 hours of any emergency admission. When you or your provider call, it will be necessary to provide the program with your name, the patient's name, the name of the physician or practitioner and hospital, the reason for the hospitalization and any other information needed to complete the review. In some cases, you may be asked for more information or a second opinion may be required to complete the review. Preauthorization - Preauthorization is necessary to determine if certain services and supplies are covered under this plan and if you meet the plan's eligibility requirements. PacificSource reviews new technologies and standards of medical practice on an ongoing basis and therefore the list of preauthorization requirements is subject to changes and updates. The current list of procedures and services that require preauthorization under the plan can be found the PacificSource' website: PacificSource.com. The list of services that require preauthorization is not intended to suggest that all the items included are necessarily covered by the benefits of this plan. A request for preauthorization must be made to PacificSource as soon as the patient knows that he or she will be receiving services for which preauthorization is required. Your medical provider can request preauthorization from PacificSource by phone - (888) 977-9299, fax - (541) 684-5264, or mail: PacificSource Health Plans PO Box 7068, Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 Espanol (800) 624-6052, extension 1009 cs@pacificsource.com If your provider will not request preauthorization for you, you may contact PacificSource yourself. In some cases, you may be asked for more information or be required to obtain a second opinion before a benefit determination can be made. If you are preauthorized for one facility, but are then transferred to another facility you wit[ need to obtain preauthorization for the new facility before transferring, except in the case of emergencies in which case notification must be made as soon as possible after transferring facilities. If your provider's preauthorization request is denied as not medically necessary or as experimental, your provider may appeal the adverse benefit determination. You retain the right to appeal the adverse benefit determination independent from your provider. Note: A preauthorization determination is valid for 90 days. However, if your coverage under the plan ends before the services are rendered or supplies received, the preauthorization determination will become invalid. SPD 0714_City of Ashland Parks Final 55 Case Management The primary objective of large case management is to identify and coordinate cost-effective medical care alternatives and to help manage the care of patients who have special or extended care illnesses or injuries. Large case management also monitors the care of the patient, offers emotional support to the family, and coordinates communications among health care providers, patients and others. Benefits may be modified by the Plan Sponsor to permit a method of treatment not expressly provided for, but not prohibited by law, rules or public policy, if the Plan Sponsor determines that such modification is medically necessary and is more cost-effective than continuing a benefit to which you or your eligible dependents may otherwise be entitled. The Plan Sponsor also reserves the right to limit payment for services to those amounts which would have been charged had the service been provided in the most cost-effective setting in which the service could safely have been provided. Examples of illnesses or injuries that may be appropriate for large case management include, but are not limited to: • Terminal illnesses (Cancer, AIDS, Multiple Sclerosis, Renal Failure, Obstructive Pulmonary Disease, Cardiac conditions, etc.) • Accident victims requiring long-term rehabilitative care • Newborns with high-risk complications or multiple birth defects • Diagnoses involving long-term IV therapy • Illnesses not responding to medical care • Child and adolescent mental/nervous disorders • Organ transplants Individual Benefits Management Individual benefits management addresses, as an alternative to providing covered services, PacificSource's consideration of economically justified alternative benefits. The decision to allow alternative benefits will be made by on a case-by-case basis. The determination to cover and pay for alternative benefits for an individual shall not be deemed to waive, alter or affect the Plan Sponsor's or PacificSource's right to reject any other or subsequent request or recommendation. The Plan Sponsor may provide alternative benefits if PacificSource and the individual's attending provider concur in the request for and in the advisability of alternative benefits in lieu of specified covered services, and, in addition, PacificSource concludes that substantial future expenditures for covered services for the individual could be significantly diminished by providing such alternative benefits under the individual benefit management program (See Case Management above). HOW TO USE YOUR DENTAL PLAN When you need dental care, you may visit any dentist. Most dental offices will bill PacificSource directly. If your dentist has any questions regarding billing procedures, he or she can call PacificSource at (541) 225-1981, or (866) 373-7053 from outside the Eugene-Springfield area. When you first visit your dentist after becoming covered under this plan, let the office staff know you have dental benefits through PacificSource. You will need to show your PacificSource ID card, which contains your group number and benefit information. Your dentist may submit claims and treatment programs on a standard American Dental Association form. For extensive dental work, PacificSource recommends that your dentist submit a pre-treatment estimate to PacificSource. PacificSource then determines how much your plan will pay toward the proposed treatment and review the estimate with your dentist prior to treatment. If your covered family members require extensive dental work, be sure your member ID number and group number are included on their pre-treatment form for identification purposes. DENTAL PLAN BENEFITS When this plan pays for dental services, it actually pays the stated percentage of charges based on reasonable and customary charges. A charge is reasonable and customary when it falls within a general range of charges being made by most dental providers in your service area for similar SPD 0714_City of Ashland Parks Final 56 treatment of similar dental conditions. If the charge for a treatment or service is more than the reasonable and customary charge in your service area, you may be required to pay the difference. The reasonable and customary charge for dental expense is the 'covered charge' referred to in this booklet. If you or your covered family member selects a more expensive treatment than is customarily provided, this plan will pay the applicable percentage of the lesser fee. You will be responsible for the balance of the provider's charges. With the Advantage Network, participating dentists agree to write off any charges over and above the negotiated, contracted fees for most services. When you use a participating dentist in the Advantage Network, you will not be responsible for any excess charges and will pay only your plan's deductible and/or co-insurance amount. If you choose not to use a participating Advantage Network dentist, or don't have access to them, reimbursement will continue to be based on usual, customary, and reasonable (UCR) charges. If that non-participating dentist's fees exceed the UCR charges, the excess charges are also your responsibility COVERED DENTAL SERVICES This dental plan covers the following services when performed by an eligible provider and when determined to be necessary by the standards of generally accepted dental practice for the prevention or treatment of oral disease or for accidental injury, including masticatory function. Covered services may also be provided by a dental hygienist or denturist to the extent that he or she is operating within the scope of his or her license as required under law in the State of Oregon. Covered dental services are organized into three classes, starting with preventive care and advancing into specialized dental procedures. Class i Services - Diagnostic and Preventive Treatment • Examinations (routine or other diagnostic exams) are covered. Separate charges for review of a proposed treatment plan or for diagnostic aids such as study models and certain lab tests are not covered. • Full mouth x-rays and/or panorex are covered up to one complete mouth series and/or panorex in any three-year period and limited to four bite-wing films in a six-month period. When an accumulative charge for additional periapical x-rays in a one-year period matches that of a complete mouth series, no further benefits for periapical x-rays or panorex are available for the remainder of the year. • Dental cleanings (prophylaxis and periodontal maintenance) are covered to a combined total of three procedures per person per benefit year. The limitation for dental cleaning applies to any combination of prophylaxis and/or periodontal maintenance in the benefit year. A separate charge for periodontal charting is not a covered benefit. Periodontal maintenance is not covered when performed within three months of periodontal scaling and root planing and/or curettage. • Topical applications of fluoride are covered to two applications per benefit year through age 22. • Fluoride varnish applications are covered to 12 applications per benefit year for children age 12 and under if the child is deemed at risk for dental infection. • The application of sealants is covered to one application in a five-year period to permanent molars and bicuspids and only for individuals through age 17. • Vizilite is a covered up to two screenings per benefit year. • Benefits for athletic mouth guards are limited to one per lifetime through age 17 if the member is still in secondary school. • Benefits for brush biopsies used to aid in the diagnosis of oral cancer are covered. Class H Restorative Services - Basic and Restorative Treatment • Composite, resin, or similar restoration in a posterior (back) tooth is covered to the amount that would be paid for a corresponding amalgam restoration. A separate charge for anesthesia when used during restorative procedures is not a covered benefit. Only one filling is allowed per tooth surface. The Plan Sponsorwill pay for a filling on a tooth surface only once per benefit year. Three or more surface fillings are limited to one per surface per benefit year. • Simple and surgical extractions of teeth and other minor oral surgery procedures are covered. SPD 0714_City of Ashland Parks Final 57 General anesthesia used in conjunction with these extractions administered by a dentist in a dental office is also covered. A separate charge for alveolectomy performed in conjunction with removal of teeth is not a covered benefit. • Periodontal scaling and root planing and/or curettage is covered but limited to only one procedure per quadrant in any 24-month period. For the purpose of this limitation, eight or fewer teeth existing in one arch will be considered one quadrant. • Benefits for full mouth debridement are limited to once every 24 months. This procedure is only covered if the teeth have not received a prophylaxis in the prior 24 months and if an evaluation cannot be performed due to the obstruction by plaque and calculus on the teeth. This procedure is not covered if performed on the same date as the prophylaxis. Class Complicated Services - Complicated Treatment • Complicated oral surgical procedures such as removal of impacted teeth are covered when preauthorized by PacificSource. Benefits for complicated oral surgical procedures include general anesthesia administered by a dentist in a dental office. A separate charge for alveolectomy performed in conjunction with removal of teeth is not a covered benefit. • Pulp capping is covered only when there is an exposure to the pulp. These are direct pulp caps. Indirect pulp caps are not covered. • Pulpotomy is covered only for deciduous teeth. • Root canal therapy is covered on the same tooth only for one charge in a three-year period. • Periodontal surgery is covered when the procedure is preauthorized by PacificSource and accompanied by a periodontal diagnosis and history of conservative (non-surgical) periodontal treatment. • Tooth desensitization is covered as a separate procedure from other dental treatment. • Space maintainers are a covered benefit for individuals through the age of 13. Class Services - Major Treatment • Crowns and other cast or laboratory-processed restorations are covered but limited to the restoration of any one tooth in a five-year period. If a tooth can be restored with a material such as amalgam or composite resin, covered charges are limited to the cost of amalgam or non-laboratory composite resin restoration even if another type of restoration is selected by the patient and/or dentist. • Replacement of an existing prosthetic device is covered only when the device being replaced is unserviceable, cannot be made serviceable, and has been in place for at least five years. • Cast partial denture, full, immediate, or overdenture are covered only to the cost of a standard full or cast partial denture. A separate charge for denture adjustments and relines performed within six months of the initial placement is not a covered benefit. Benefits for subsequent relines are provided only once in a 12-month period. Cast restorations for partial denture abutment teeth or for splinting purposes are not covered unless the tooth in and of itself requires a cast restoration. • Fixed bridges or removable cast partials are covered. Benefits for temporary full or partial dentures must be preauthorized. Benefits for the initial placement of full or partial dentures or fixed bridges (including acid-etch metal bridges) are provided only if the denture or bridgework includes replacement of a natural tooth which is extracted or lost while the member's coverage is in effect. However, this limitation does not apply after the member has been covered under the policyholder's group dental plan for a period of at least 36 consecutive months. • Benefits for the surgical placement and removal of implants are limited to once per lifetime per tooth space for each service. Services must be preauthorized by PacificSource to be covered. Benefits include final crown and implant abutment over a single implant and final implant-supported bridge abutment and implant abutment or pontic. An alternative benefit per arch of a conventional full or partial denture for the final implant-supported full or partial denture prosthetic device is available. • Bruxism splint and nightguard (appliances to reduce or prevent pain or damage from grinding of teeth) are covered. SPD 0714_City of Ashland Parks Final 58 ORTHODONTIA BENEFITS This plan pays 50% of the usual, customary, and reasonable for orthodontics for all covered individuals. The lifetime maximum amount payable for orthodontic benefits is $1,000 per person. EXCLUDED DENTAL SERVICES This plan does not provide benefits in any of the following circumstances or for any of the following conditions: • Aesthetic dental procedures - Services and supplies provided in connection with dental procedures that are primarily aesthetic, including bleaching of teeth and labial veneers. • Antimicrobial agents - Localized delivery of antimicrobial agents into diseased crevicular tissue via a controlled release vehicle. • Benefits not stated - Any services and supplies not specifically described as covered benefits under this plan • Biopsies or histopathologic exams - A separate charge for a biopsy of oral tissue or histopathologic exam. • Bone replacement grafts to prepare sockets for implants after tooth extraction. • Charges for broken appointments • Collection of cultures and specimens. • Connector bar or stress breaker. • Core build-ups are not covered unless used to restore a tooth that has been treated endodontically (root canal). • Cosmetic/reconstructive services and supplies - Procedures, appliances, restorations, or other services that are primarily for cosmetic purposes. This includes services or supplies rendered primarily to correct congenital or developmental malformations, including but not limited to, peg laterals, cleft palate, maxillary and mandibular (upper and lower jaw) malformation, enamel hypoplasia, and fluorosis (discoloration of teeth). However, the replacement of congenitally missing teeth is covered. • Denture replacement made by necessary by loss, theft, or breakage. • Diagnostic casts - Diagnostic casts (study models), gnathological recordings, occlusal appliances, occlusal equilibration procedures, or similar procedures. • Drugs and medications that are prescribed drugs, premedication drugs, analgesics (e.g., nitrous oxide or non-intravenous sedation), any other euphoric drugs, or any take-home medicine or supplies distributed by a provider. • Educational programs - Instructions and/or training in plaque control and oral hygiene. • Experimental or investigational procedures - Services, supplies, protocols, procedures, devices, drugs or medicines, or the use thereof that are experimental or investigational for the diagnosis and treatment of the patient. An experimental or investigational service is not made eligible for benefits by the fact that other treatment is considered by the member's dental care provider to be ineffective or not as effective as the service or that the service is prescribed as the most likely to prolong life. • Fractures of the mandible - Services and supplies provided in connection with the treatment of simple or compound fractures of the mandible. • General anesthesia except when administered by a dentist in connection with oral surgery in his/her office • Gingivetomcy, gingivoplasty or crown lengthening in conjunction with crown preparation or fixed bridge services done on the same date of service. • Hospital charges or additional fees charged by the dentist for hospital treatment • Hypnosis • Infection control - A separate charge for infection control or sterilization SPD 0714_City of Ashland Parks Final 59 • Intra and extra coronal splinting - Devices and procedures for intra and extra coronal splinting to stabilize mobile teeth. • Oral Surgery treating any fractured jaw • Orthodontic services - Treatment of malalignment of teeth and/or jaws, or any ancillary services expressly performed because of orthodontic treatment, unless your Dental Benefit Summary shows orthodontic services as a covered benefit. • Orthognathic surgery - Surgery to manipulate facial bones, including the jaw, in patients with facial bone abnormalities performed to restore the proper anatomic and functional relationship to the facial bones • Periodontal probing, charting, and re-evaluations • Photographic images. • Pin retention in addition to restoration. • Precision attachments • Pulpotomies on permanent teeth • Removal of clinically serviceable amalgam restorations to be replaced by other materials free of mercury, except with proof of allergy to mercury. • Services covered by the member's medical plan. • Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. • Services otherwise available - These include but are not limited to: - Services or supplies for which payment could be obtained in whole or in part if the member applied for payment under any city, county, state, or federal law (except Medicaid); and - Services or supplies the member could have received in a hospital or program operated by a federal government agency or authority. Covered expenses for services or supplies furnished to a member by the Veterans' Administration of the United States that are not service-related are eligible for payment according to the terms of this policy. - Services or supplies for which payment would be made by Medicare. • Services or supplies for which no charge is made which you are not legally required to pay or which a provider or facility is not licensed to provide even though the service or supply may otherwise be eligible. This includes services provided by you or an immediate family member. • Sinus lift grafts to prepare sinus site for implants. • Temporomandibular joint (TMJ) - Any services or supplies for treatment of any disturbance of the Temporomandibular joint. • Third party liability, motor vehicle liability, motor vehicle insurance coverage, workers' compensation - Any services or supplies for illness or injury for which a third party is responsible or which are payable by such third party or which are payable pursuant to applicable workers' compensation laws, motor vehicle liability, uninsured motorist, underinsured motorist, and personal injury protection insurance and any other liability and voluntary medical or dental payment insurance to the extent of any recovery received from or on behalf of such sources. • Tooth transplantation - Services and supplies provided in connection with tooth transplantation, including re-implantation from one site to another and splinting and/or stabilization. This exclusion does not relate to the re-implantation of a tooth into its original socket after it has been avulsed. • Treatment after coverage ends - Services or supplies provided after enrollment in this plan ends. The only exception is for Class III Services ordered and fitted before enrollment ends and placed within 31 days after enrollment ends. • Treatment not dentally necessary according to acceptable dental practice or treatment not likely to have a reasonably favorable prognosis. • Treatment prior to enrollment - Dental services begun before you or your family member became eligible for those services under this plan. SPD 0714_City of Ashland Parks Final 60 • Treatment while incarcerated - Services or supplies received while in the custody of any state or federal law enforcement authorities or while in jail or prison. • Unwilling to release information - Charges for services or supplies for which you are unwilling to release medical or dental information necessary to determine eligibility for payment under this policy • War-related conditions - The treatment of any condition caused by or arising out of an act of war, armed invasion, or aggression, or while in the service of the armed forces. • Work-related conditions - Services or supplies for treatment of illness or injury arising out of or in the course of employment or self-employment for wages or profit, whether or not the expense for the service or supply is paid under workers' compensation. CLAIMS PROCEDURES How to File/How to Appeal a Claim These claim procedures describe how benefit claims and appeals are made and decided under this plan. Only members or a designated authorized representative may submit claims for benefits (for themselves and on behalf of their covered dependents), and benefits will only be paid to the member or the actual provider of services. Under the following claims procedures section, the words 'you' and `your' will mean a member of the group health plan of the Plan Sponsor. You become a claimant when you make a request for a plan benefit or benefits in accordance with these claims procedures. You and your covered dependents have the right to elect group health care benefits as offered by the Plan Sponsor, and your and their rights will be determined under the plan's provisions and in conjunction with the claims and appeals procedures outlined later in this section. Claims will also be considered filed by you if communications and requests for benefits come from an individual that you have designated as your authorized representative to act on your behalf with respect to a claim. In the event that you designate an authorized representative to act on your behalf, the plan will send all notifications, requests for further information, appeal decisions, and all other communications to your authorized representative and provide you with a copy of all communications, unless you request otherwise in writing. An authorized representative may act on behalf of a claimant with respect to benefit claim or appeal under these procedures. However, no person (including a treating health care professional) will be recognized as an authorized representative until the plan receives an Designation of Authorized Representative form signed by the claimant, except that for urgent care claims the plan shall, even in the absence of a signed Designation of Authorized Representative form, recognize a health care professional with knowledge of the claimant's medical condition (e.g., the treating physician or practitioner) as the claimant's authorized representative unless the claimant provides specific written direction otherwise. A Designation of Authorized Representative form may be obtained from and completed forms must be returned to: PacificSource Health Plans PO Box 7068, Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 Espanol (800) 624-6052, extension 1009 cs@pacificsource.com An assignment for purposes of payment (e.g., to a health professional) does not constitute appointment of an authorized representative under these claims procedures. However, unless you have directed the plan otherwise, claims submitted on your behalf by a health care professional will be considered a valid claim if submitted pursuant to the guidelines outlined in these claim procedures. Any reference in these claims procedures to the claimant is intended to include the authorized representative of such claimant appointed in compliance with the above procedures. For the purposes of the claims procedures section, any reference to 'days' will refer to calendar days, not business days. SPD 0714_City of Ashland Parks Final 61 Questions about Your Claims PacificSource is available to listen and help with any concerns or problems you may have with resolving a claim. Because PacificSource wants you to be completely satisfied with the member services assistance you receive, a process has been established for addressing your concerns and solving your problems. If you have a concern regarding a person, a service, the quality of care, or you want to inquire about what benefits are covered under the plan, please call PacificSource at (888) 977-9299 and explain your concern to one of their Customer Service Representatives. You may also express that concern in writing. PacificSource will do their best to resolve the matter on your initial contact. If PacificSource needs more time to review or investigate your concern, they will get back to you as soon as possible, but in any case within 30 days. They will not consider any of these communications to be a `claim' for benefits. A formal claim for benefits must meet certain other standards which are described in greater detail in these procedures. Types of Claims Pre-Service Claims - The plan subjects the receipt of benefits for some services or supplies to a preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it may in some cases be conducted on a post-service basis. Unless a response is needed sooner due to the urgency of the situation, a pre-service preauthorization review will be completed and notification made to you and your medical provider as soon as possible, generally within two working days, but no later than 15 days within receipt of the request. Urgent Care Claims - If the time period for making a non-urgent care determination could seriously jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain that cannot be adequately managed without the care or treatment that is proposed, a preauthorization review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours within receipt of the request. Concurrent Care Review - A concurrent care decision occurs when a previously approved course of treatment is reconsidered and reduced or denied, or where an extension is requested beyond the initially approved period of time or number of treatments. Inpatient hospital or rehabilitative facilities, skilled nursing facilities, intensive outpatient, and residential behavioral health care require concurrent review for a benefit determination with regard to an appropriate length of stay or duration of service. Benefit determinations will be made as soon as possible within receipt of all the information necessary to make such a determination. Post-Service Claims - A claim determination that involves only the potential payment of reimbursement of the cost of medical care that has already been provided will be made as soon as reasonably possible but no later than 30 days from the day after receiving the claim. How to File a Claim Most health care providers will file claims on your behalf. Electronically submitted claims are processed most efficiently. If unable to file electronically, you, your health care provider, or an authorized representative must file your claim using HCFA-1500 (revision 12/90 and later), UB92, or ADA (revision 12/90 and later) forms, or an itemized statement. These forms are available from your health care provider or PacificSource. A claim will be considered filed when it is received by PacificSource at the address listed below: PacificSource Health Plans PO Box 7068, Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 Espanol (800) 624-6052, extension 1009 cs@pacificsource.com The following information is required in order qualify your request for benefits as a properly submitted claim: • Plan member's name, member ID and current address; • Patient's name, member ID and address if different from the member's; • Provider's name, tax identification number, address, degree and signature; SPD 0714_City of Ashland Parks Final 62 • Date(s) of service(s); • Place of service(s); • Diagnostic Code; • Procedure Codes (describes the treatment or services rendered); • Assignment of Benefits, signed (if payment is to be made to the provider); • Release of Information Statement, signed; and • Explanation of Benefits (EOB) information if another plan is the primary payer. This plan also recognizes the following actions and submission of forms as claims: • A request by you for benefits through preauthorization in cases where use of preauthorization is required in order to obtain a particular benefit. • Requests by your formally-designated authorized representative for preauthorization in cases where use of preauthorization is required in order to obtain a particular benefit. The plan will take reasonable steps to determine whether an individual claiming to be acting on your behalf is, in fact, validly empowered to do so under the circumstances, and the plan will require that you complete and file a form identifying any person you authorize to act on your behalf with respect to a claim. However, when inquiries by a health care provider relate to payments due to the provider-rather than due to you-under participating provider contracts (where the health care provider has no recourse against you for the amounts) such inquiries by a health care provider will not be considered 'claims' by the plan. • Requests for benefits (in the case of a claim involving urgent care) by a health care provider with knowledge of your medical condition. For urgent care claims, you are not required to complete a form and formally designate a health care provider as your representative with respect to a claim. Claims must be submitted individually for each claimant. Please do not staple claims together. Send completed information to: PacificSource Health Plans PO Box 7068, Springfield OR 97475-0068 Phone (541) 684-5582 or (888) 977-9299 Espanol (800) 624-6052, extension 1009 cs@pacificsource.com If you have any questions regarding your eligibility, benefits or claims information, please call PacificSource at: (888) 977-9299. All claims for benefits must be submitted to the plan within 90 days of the date of service. If it is not possible to submit a claim within 90 days, you should submit the claim as soon as possible. In some cases the plan will accept the late claim. The plan, however, will not pay a claim that was submitted more than one year after the date of service. All submitted claims and appeals will fall into one of the categories described previously. The handling of your initial claim or later appeal will be governed, in all respects, by the appropriate category of claim or appeal, and each time your claim or appeal is examined, a new determination will be made regarding the category into which the claim or appeal falls at that particular time. Pre-service claims - Your plan subjects the receipt of benefits for some services or supplies to a preauthorization review. Although a preauthorization review is generally done on a pre-service basis, it may in some case be conducted on a post-service basis. Unless a response is needed sooner due to the urgency of the situation, a pre-service preauthorization review will be completed and notification made to you and your medical provider as soon as possible, generally within two working days, but no later than 15 days within receipt of the request. Urgent care claims - If the time period for making a non-urgent care determination could seriously jeopardize your life, health or ability to regain maximum function, or would subject you to severe pain that cannot be adequately managed without the care or treatment that is proposed, a preauthorization review will be completed as soon as possible, generally within 24 hours, but no later than 72 hours of receipt of the request. SPD 0714_City of Ashland Parks Final 63 Concurrent care review - Inpatient hospital or rehabilitation facilities, skilled nursing facilities, intensive outpatient, and residential behavioral healthcare require concurrent review for a benefit determination with regard to an appropriate length of stay or duration of service. Benefit determinations will be made as soon as possible but no later than one working day after receipt of all the information necessary to make such a determination. Post-service claims - A claim determination that involves only the payment of reimbursement of the cost of medical care that has already been provided will be made as soon as reasonably possible but no later than 30 days from the day after receiving the claim. Retrospective review - A claim for benefits for which the service or supply requires a preauthorization review but was not submitted for review on a pre-service basis will be reviewed on a retrospective basis within 30 working days after receipt of the information necessary to make a claim determination. Extension of time - Despite the specified timeframes, nothing prevents the member from voluntarily agreeing to extend the above timeframes. Unless additional information is needed to process your claim, PacificSource will make every effort to meet the timeframes stated above. If a claim cannot be paid within the stated timeframes because additional information is needed, PacificSource will acknowledge receipt of the claim and explain why payment is delayed. If PacificSource does not receive the necessary information within 15 days of the delay notice, PacificSource will either deny the claim or notify you every 45 days while the claim remains under investigation. No extension is permitted for urgent care claims. Extension of time - Unless additional information is needed to process your claim, the plan will make every effort to meet the timeframes stated above. If a claim cannot be paid within the stated timeframes because additional information is needed, PacificSource will acknowledge receipt of the claim and explain why payment is delayed. If they do not receive the necessary information within 15 days of the delay notice, they will either deny the claim or notify you every 45 days while the claim remains under investigation. Adverse benefit determinations - Any denial, reduction or termination of, or failure to provide or make a payment for a benefit based on: • A determination that the member is not eligible to participate in the plan. • A determination that the benefit is not covered by the plan. • The imposing of limits, such as source-of-injury exclusions. • A determination that the benefit is experimental, investigational or not medically necessary or medically appropriate. An adverse benefit determination made to reduce or deny benefits applied for a pre-service, post- service, or concurrent care basis may be appealed in accordance with the plan's appeals procedures described later in this section. Incomplete Claims If any information needed to process a claim is missing, the claim shall be treated as an incomplete claim. Other Incomplete Claims - If a pre-service or post-service claim is incomplete, the plan may deny the claim or may take an extension of time, as described above. If the plan takes an extension of time, the extension notice shall include a description of the missing information and shall specify a timeframe, no less than 45 days, in which the necessary information must be provided. The timeframe for deciding the claim shall be suspended from the date the extension notice is received by the claimant until the date the missing necessary information is provided to the plan. If the requested information is provided, the plan shall decide the claim within the extension period specified in the extension notice. If the requested information is not provided within the time specified, the claim may be decided without that information. If you fail to follow the plan's filing procedures because your request for benefits does not: 1) identify the patient; 2) note a specific medical condition or symptom; 3) describe a specific treatment, service, or product for which approval is requested; or 4) is not sent to the correct address, you will not have submitted a claim. You will be notified orally, and/or by written notification if requested by the claimant, within 24 hours, that you have failed to follow the filing procedures, and you will be reminded of the proper filing procedures. SPD 0714_City of Ashland Parks Final 64 Notification of Benefit Determination The plan will pay the benefit according to plan provisions. This may mean that less than 100% of your claim is payable by the plan. In each case where the plan pays benefits or determines that it is not responsible for your medical claim, you will receive an Explanation of Benefits which will outline the basis for the plan's payment. If your claim is denied or payable at a level less than outlined in this Summary Plan Description, you are entitled to appeal the decision under the rules governing adverse benefit determination. Adverse Benefit Determination • Written notification will be provided to you of the plan's adverse benefit determination (as defined in the How To File A Claim section above) and will include the following: • Information sufficient to identify the claim involved, including the date of service, the health care provider, and the claim amount (if applicable), as well as how to obtain the diagnosis code, the treatment code, and the corresponding meanings of these codes. • A statement of the specific reason(s) for the decision; • Reference(s) to the specific plan provision(s) on which the determination is based; • A description of any additional material or information necessary to perfect the claim and why such information is necessary; • A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination or a statement that such information will be provided free of charge upon request; • If the determination involves scientific or clinical judgment, disclose either (a) an explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's medical circumstances, or (b) a statement that such explanation will be provided at no charge upon request; • In the case of an urgent care claim, an explanation of the expedited review methods available for such claims; and • A statement regarding the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman. Notification of the plan's adverse benefit determination on an urgent care claim may be provided orally, but written notification shall be furnished not later than three days after the oral notice. You may call the Third Party Administrator at (888) 977-9299 to discuss the adverse benefit determination if you have concerns. You may also express those concerns in writing and if needed, may submit additional information that you believe would clarify any of the circumstances that lead to the adverse benefit determination. Third Party Administrator will not consider any of these questions or clarifications to be a formal appeal unless you specifically state it as such. The process for filing a formal appeal is listed below. Your Right to Appeal You have the right to appeal an adverse benefit determination under these claims procedures. If you choose to appeal the plan's adverse benefit determination, your appeal will be governed by rules that assure you a full and fair review. If you are denied benefits based upon the plan's finding that you are/were ineligible for benefits, the denial of benefits gives you the opportunity to appeal the plan's decision. If the plan decides to reduce or terminate benefits for your previously-approved course of treatment, the plan's decision will be treated as an adverse benefit determination, and the plan will provide you reasonable advance notice of the reduction or termination to allow you to appeal the plan's decision before the benefit reduction or termination takes place. If you decide to appeal the plan's decision, you must follow the rules for appealing a plan's decision. No lawsuit can be instituted until the claimant has exhausted the plan's internal and external claims review and appeals procedures. No lawsuit can be instituted more than one year after the date of the notice to the claimant that a claim appeal has been denied. SPD 0714_City of Ashland Parks Final 65 Appealing an Initial Claim Determination - You must submit a written request to the plan within 180 days of receipt of an adverse benefit determination in order to initiate an appeal. An oral request for review is acceptable for urgent care claims and may be made by calling the Third Party Administrator at (888) 977-9299 and asking the plan to register your oral appeal. When you appeal an adverse benefit determination, the plan will provide a full and fair review which will include the following features: • You will have the opportunity to submit written comments, documents, records, and other information related to the claim. • At your request (and free of charge), you will be provided with reasonable access to (and copies of) all documents, records, and other information relevant to your claim for benefits. Included in this category are any documents, records or other information in your claim file, whether or not those materials were relied upon by the plan in making its adverse benefit determination. You also have the right to review documentation showing that the plan followed its own internal processes for ensuring appropriate decision making. • The review of your claim will take into account all comments, documents and other information without regard to whether such information was submitted or considered in the initial benefit determination. • Any appeal of an adverse benefit determination will not give deference to the initial decision on your claim, and the review will be conducted by a designated plan representative who did not make the original determination and does not report to the plan representative who made the original determination. • In deciding an appeal of any adverse benefit determination that is based on a medical judgment (including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or medically appropriate), the designated plan representative will consult with a health care professional who has appropriate training and experience in the particular field of medicine involved in the medical judgment. This health care professional will not be the same professional who was originally consulted in connection with the adverse determination; neither will this health care professional report to the health care professional who was consulted in connection with the adverse determination. The plan will uphold the findings of the independent review in responding to the appeal. • The plan will identify medical or vocational experts whose advice was obtained on behalf of the plan in connection with an adverse benefit determination of your claim, whether or not that advice was relied upon in making the benefit determination. You must first follow this appeal process before taking any outside legal action. After you submit the claim for appeal, the plan will make a decision on your appeal as follows: Appeal of Urgent Care Claims - The plan's expedited appeal process for urgent care claims will allow you to request (orally or in writing) an expedited appeal, after which, all necessary information, including the plan's benefit determination on review, will be transmitted between the plan and you by telephone, fax, or other expeditious method. You will be notified (in writing or electronically) of the benefit determination as soon as possible, but not later than 72 hours after the plan receives the request for review of the prior benefit determination. For urgent care claims you may also be able to request an independent external review take place at the same time as you pursue the plan's internal appeal process. Appeal of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will be notified (in writing or electronically) of the benefit determination within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days. Appeal of Concurrent Care Claims - For concurrent care claims, you will be notified (in writing or electronically) of the benefit determination with reasonable advance notice before the benefit reduction or termination takes place. Appeal of Post-Service Claims - For post-service claims, you will be notified (in writing or electronically) of the benefit determination within a reasonable period of time, but not later than 60 days. Denial of Claim on Appeal - If your appealed claim is denied, the plan will send you written or electronic notification that explains why your appealed claim was denied and shall include the following: SPD 0714_City of Ashland Parks Final 66 • A statement of the specific reason(s) for the decision; • Reference(s) to the specific plan provision(s) on which the determination is based; • A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination or a statement that such information will be provided free of charge upon request; • If the determination involves scientific or clinical judgment, the plan will disclose either (a) an explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's medical circumstances, or (b) a statement that such explanation will be provided at no charge upon request; and • A statement indicating your right to receive, upon request (and free of charge), reasonable access to (and copies of) all documents, records, and other information relevant to the determination. Included in this category are any documents, records or other information in your claim file, whether or not those materials were relied upon by the plan in making its adverse determination. Additional Level of Review - If you are dissatisfied with the outcome of your appeal, you may request an additional review. The City of Ashland or its designated representative is responsible for handling and for making a determination on any additional level of review. To initiate this review you should follow the same process required for an appeal. You must submit a written request for additional review within 60 days following the receipt of the appeal decision. When you submit a request for additional review of an adverse benefit determination, the plan will provide a full and fair review which will include the following features: • You will have the opportunity to submit written comments, documents, records, and other information related to the claim. • At your request (and free of charge), you will be provided with reasonable access to (and copies of) all documents, records, and other information relevant to your claim for benefits. Included in this category are any documents, records or other information in your claim file, whether or not those materials were relied upon by the plan in making its adverse benefit determination. You also have the right to review documentation showing that the plan followed its own internal processes for ensuring appropriate decision making. • The review of your claim will take into account all comments, documents and other information without regard to whether such information was submitted or considered in the initial adverse benefit determination. • Additional review will not afford deference to the appeal determination, and the review will be conducted by a designated plan representative who did not make the original determination and does not report to the plan representative who made the original determination. • In deciding an appeal of any adverse benefit determination that is based on a medical judgment (including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or medically appropriate), the designated plan representative will consult with a health care professional who has appropriate training and experience in the particular field of medicine involved in the medical judgment. This health care professional will not be the same professional who was originally consulted in connection with the adverse determination; neither will this health care professional report to the health care professional who was consulted in connection with the adverse determination. The plan will uphold the findings of the independent review in responding to the appeal. • The plan will identify medical or vocational experts whose advice was obtained on behalf of the plan in connection with an adverse benefit determination of your claim, whether or not that advice was relied upon in making the benefit determination. After you submit the claim for additional review, the plan will make a decision on your appeal as follows: Additional Review of Urgent Care Claims - The plan's expedited additional review process for urgent care claims will allow you to request (orally or in writing) an expedited review, after which, all necessary information, including the plan's benefit determination on review, will be transmitted between the plan and you by telephone, fax, or other expeditious method. You will be notified (in writing or electronically) of the benefit determination as soon as possible, but not later than 72 hours after the plan receives the request for the review. SPD 0714_City of Ashland Parks Final 67 Additional Review of Non-Urgent Pre-Service Claims - For non-urgent pre-service claims, you will be notified (in writing or electronically) of the review outcome within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days. Additional Review of Concurrent Care Claims - For concurrent care claims, you will be notified (in writing or electronically) of the review outcome with reasonable advance notice before the benefit reduction or termination takes place. Additional Review of Post-Service Claims - For post-service claims, you will be notified (in writing or electronically) of the review outcome within a reasonable period of time, but not later than 60 days. Denial of Claim after Additional Review - If after your request for additional review the claim is denied, the plan will send you written or electronic notification that explains why the additional review upheld the denial and shall include the following: • A statement of the specific reason(s) for the decision; • Reference(s) to the specific plan provision(s) on which the determination is based; • A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination or a statement that such information will be provided free of charge upon request; • If the determination involves scientific or clinical judgment, the plan will disclose either (a) an explanation of the scientific or clinical judgment applying the terms of the plan to the claimant's medical circumstances, or (b) a statement that such explanation will be provided at no charge upon request; and • A statement indicating your right to receive, upon request (and free of charge), reasonable access to (and copies of) all documents, records, and other information relevant to the determination. Included in this category are any documents, records or other information in your claim file, whether or not those materials were relied upon by the plan in making its adverse determination. Independent External Review - You may have the right to have your case reviewed by an external independent review organization. Only decisions that are based on issues related to medical necessity, medical appropriateness, health care setting, level of care, or effectiveness of a covered benefit may be appealed to an external independent review organization. The plan must contract with at least three different independent external review organizations and must rotate between them on a random or circulating basis. Your request for an independent review must be made in writing to PacificSource within 180 days of the date of the final internal adverse benefit determination. You may include additional written information, which will be included with the documents PacificSource provides to the independent review organization. A final decision made by an independent review organization is binding on the Plan Sponsor. This decision is also binding on you, except to the extent other remedies are available under state or federal law. In certain instances you may be able to request an expedited review process, such as when the timeframe for completion of the internal appeals process would seriously jeopardize the life or health of the claimant or their ability to regain maximum function, or if the final adverse benefit determination concerns an admission, availability of care, continued stay or health care service for which the claimant received emergency services, but has not been discharged from a facility. Resources For Information And Assistance Assistance in Other Languages Members who do not speak English may contact PacificSource's Customer Service Department for assistance. They can usually arrange for a multilingual staff member or interpreter to speak with them in their native language. Information Available from PacificSource PacificSource makes the following written information available to you free of charge. You may contact their Customer Service Department by phone, mail, or email to request any of the following: SPD 0714_City of Ashland Parks Final 68 • A directory of participating healthcare providers under your plan • Information about PacificSource's drug formulary • A copy of PacificSource's annual report on complaints and appeals • A description (consistent with risk-sharing information required by the Centers for Medicare and Medicaid Services, formerly known as Health Care Financing Administration) of any risk-sharing arrangements PacificSource has with providers • A description of PacificSource's efforts to monitor and improve the quality of health services • Information about how PacificSource checks the credentials of PacificSource's network providers and how you can obtain the names and qualifications of your healthcare providers • Information about PacificSource's preauthorization procedures • Information about any healthcare plan offered by the Plan Sponsor Information Available from the Oregon Insurance Division The following consumer information is available from the Oregon Insurance Division: • The results of all publicly available accreditation surveys • A summary of PacificSource's health promotion and disease prevention activities • Samples of the written summaries delivered to PacificSource policyholders • An annual summary of grievances and appeals against PacificSource • An annual summary of PacificSource's quality assessment activities • An annual summary of the scope of PacificSource's provider network and accessibility of healthcare services You can request this information by contacting the Oregon Insurance Division by writing to the Oregon Insurance Division, Consumer Advocacy Unit, PO Box 14489, Salem, OR 97309-0405 or by phone at (503) 947-7984, or the toll-free message line at (888) 877-4894, on the Internet at http://insurance.oregon.gov/consumer/consumer.htm1, or by email at cp.ins@state.or.us. Plan Sponsor's Discretionary Authority; Standard of Review The Plan Sponsor is the sole fiduciary of the plan, and exercises all discretionary authority and control over the administration of the plan and the management and disposition of plan assets. Benefits under the plan will be paid only if the Plan Sponsor decides, in its discretion, that the member or beneficiary is entitled to such benefits. Any construction of the terms of any plan document and any determination of fact adopted by the Plan Sponsor shall be final and legally binding on the parties. A court of law or arbitrator reviewing any fiduciary's decision, including one relating the plan interpretation or a benefit claim, must consider only the documents, testimony and other evidence that were presented to the fiduciary at the time the fiduciary made the decision. In addition, the court or arbitrator must use the `arbitrary and capricious' standard of review. That is, the fiduciary's determination can be reversed only if it was made in bad faith, is not supported by substantial evidence or is erroneous as to a question of law. The Plan Sponsor may hire someone to perform claims processing and other specified services in relation to the plan. Any such contractor will not be a fiduciary of the plan and will not exercise any of the discretionary authority and responsibility granted to the Plan Sponsor, as described above. Coordination of Benefits Coordinating with Other Group Health Plans - When benefits are coordinated, one plan pays benefits first (the 'primary coverage') and the other plan pays benefits second (the 'secondary coverage'). When you and/or your dependents are covered under more than one group health plan, the combined benefits payable by this plan and all other group plans will not exceed 100% of the eligible expense incurred by the individual. The plan assuming primary payer status will determine benefits first without regard to benefits provided under any other group health plan. SPD 0714_City of Ashland Parks Final 69 Note: If your primary and secondary coverage both include a deductible, you will be required to satisfy each of those deductibles before benefits will be paid. There are two types of Coordination of Benefits -'True' Coordination of Benefits and Non-Duplicating Coordination of Benefits (also called Integration of Benefits.) See the Medical Benefit Summary to determine if your plan offers True Coordination of Benefits or Non-Duplicating/Integration of Benefits. For True Coordination of Benefits, the primary plan will pay benefits first, subject to any deductibles, co-payments and co-insurance. The remaining balance will be passed on to the secondary payer. When this plan is the secondary payer, the balance of eligible expenses will be applied as if it was a new claim under this plan. Deductibles, co-payments and co-insurance relevant to this plan will be subtracted from the amount before paying the remainder. For Non-Duplicating Coordination of Benefits/Integration of Benefits, the primary plan will pay benefits first, subject to any deductibles, co-payments and co-insurance. The remaining balance will be passed on to the secondary payer. When this plan is the secondary payer, it will reimburse the balance of remaining eligible expenses, not to exceed normal plan liability if this plan had been primary. This means that if the primary payer has already paid as much as or more than this plan would have paid had this plan been primary, there will be no additional payment made. This does not apply to City of Ashland. Government Programs and Other Group Health Plans The term group health plan, as it relates to coordination of benefits, includes the government programs Medicare, Medicaid and TriCare. The regulations governing these programs take precedence over the determination of benefits under this plan. For example, in determining the benefits payable under the plan, the plan will not take into account the fact that you or any eligible dependent(s) are eligible for or receive benefits under a Medicaid plan. The term group health plan also includes all group insurance and group subscriber contracts, such as union welfare plans. Order of Payment When Coordinating with Other Group Health Plans • If the other plan does not include 'coordination of benefits,' that plan is primary and this plan is secondary. • If you are covered as an employee on one plan and a dependent on another, your Plan Sponsor's plan is primary. • When a child is covered under both parents' policies and the parents are either married or are living together (regardless of whether or not they have ever been married): - The parent whose birthday falls first in a benefit year has the primary plan; or - If both parents have the same birthday, the parent who has been covered the longest has the primary plan. • When a child is covered under both parents' plans and the parents are divorced, separated, or not living together (regardless of whether or not they have ever been married): - If a court order specifies that one parent is responsible for the child's healthcare expenses, the mandated parent's coverage is primary regardless of custody. - If a court order specifies that both parents are responsible for the child's healthcare expenses, the parent whose birthday falls first in a benefit year has the primary plan. If both parents have the same birthday, the parent who has been covered the longest has the primary plan. - If a court order specifies that both parents have joint custody without specifying that one parent has responsibility for the child's healthcare expenses, the parent whose birthday falls first in a benefit year has the primary plan. If both parents have the same birthday, the parent who has been covered the longest has the primary plan. - If there is no court order, the order of benefits for the child are as follows: o The custodial parent's coverage is primary; o The spouse of the custodial parent's coverage pays second; SPD 0714_City of Ashland Parks Final 70 o The natural parent without custody's coverage pays third; and o The spouse of the natural parent without custody's coverage pays fourth. • If a plan covers you as an active employee or a dependent of an active employee, that plan is primary. Another plan covering you as inactive, laid off, or retired is secondary. • When this plan covers you or your dependent pursuant to COBRA or under a right of continuation pursuant to other federal law, the plan covering you or your dependent as an employee, member, subscriber, or retiree or covering you or your dependent as a dependent of an employee, member, subscriber or retiree is the primary plan and this plan's coverage is the secondary plan. • If none of these rules apply, the coverage that has been in place longest is primary. Most insurers or administrators send you an explanation of benefits, or EOB, when they pay a claim. If your other plan's coverage is primary, send PacificSource the other plan's EOB with your original bill and they will process your claim. If you receive more than you should when your benefits are coordinated, you will be expected to repay any over-payment to the plan. Right to Make Payments to Other Organizations Whenever payments, which should have been made by this plan, have been made by any other plan(s), this plan has the right to pay the other plan(s) any amount necessary to satisfy the terms of this coordination of benefits provision. Amounts paid will be considered benefits paid under this plan and, to the extent of such payments, the plan will be fully released from any liability regarding the person for whom payment was made. Automobile Insurance -This plan provides benefits relating to medical expenses incurred as a result of an automobile accident on a secondary basis only. Benefits payable under this plan will be coordinated with and secondary to benefits provided or required by any no-fault automobile insurance statute, whether or not a no-fault policy is in effect, and/or any other automobile insurance. Any benefits provided by this plan will be subject to the plan's reimbursement and/or subrogation provisions. OTHER IMPORTANT PLAN PROVISIONS Assignment of Benefits All benefits payable by the plan are automatically assigned to the provider of services or supplies, unless evidence of previous payment is submitted with the claim form. However, the plan reserves the right to reimburse the member, the provider, or both jointly. Payments made in accordance with an assignment are made in good faith and release the plan's obligation to the extent of the payment. Payments will also be made in accordance with any assignment of rights required by a state Medicaid plan. Members are expressly prohibited from assigning any right to payment of benefits under a Benefit Program, including this plan. No attempts at assignment of any such expenses under a Benefit Program will be recognized. Except as may be expressly prescribed in an agreement to which the Plan Sponsor is a party, nothing contained in any written designation of coverage under a Benefit Program will make the Benefit Program, or the Plan Sponsor or any other employer, liable to any third-party to whom a member may be liable for medical care, treatment or services. Proof of Loss The Plan Sponsor has the right to require a claimant to undergo physical or psychological examinations relating to the claimant's illness, injury or condition as often as the Plan Sponsor deems reasonably necessary while the claim for benefits is pending. The Plan Sponsor also has the right to require an autopsy in case of death (where not prohibited by law). No Verbal Modifications of Plan Provisions No verbal statement made by anyone involved in administering this plan can waive any of the terms or conditions of this plan or prevent the Plan Sponsor from enforcing any provision of this plan. Waivers are valid only if they are contained in a written instrument signed by an authorized individual on behalf of the Plan Sponsor. Any such written waiver will be valid only as to the specific plan, term or condition set forth in the written instrument. Unless specifically stated otherwise, a written waiver will be valid only for the specific claim involved at the time, and will not be a continuing waiver of the term or condition in the future. SPD 0714_City of Ashland Parks Final 71 Reimbursement to the Plan This section applies whenever another party (including your own insurer under an automobile or other policy) is legally responsible or agrees to compensate you or your dependent, by settlement, verdict or otherwise, for an illness or injury. In that case, you or your dependent (or the legal representatives, estate or heirs of either you or your dependent), must promptly reimburse the plan for any benefits it paid relating to that illness or injury, up to the full amount of the compensation received from the other party (regardless of how that compensation may be characterized and regardless of whether you or your dependent have been made whole). If the plan has not yet paid benefits relating to that illness or injury, the plan may reduce or deny future benefits on the basis of the compensation received by you or your dependent. Benefits relating to such illness or injury will not be payable by the plan until you sign and return a statement, provided by the plan, acknowledging your obligation to reimburse the plan under this provision. That obligation will arise upon the payment of any plan benefits relating to the illness or injury, whether or not you sign such a statement. You or your dependent must cooperate with the plan and its authorized representatives, and must sign and deliver such documents as the plan or its agents reasonably request to protect the plan's right of reimbursement. You or your dependent must also provide any relevant information and take such actions as the plan or its agents reasonably request to assist the plan in making a full recovery of the reasonable value of the benefits provided. You or your dependent must not take any action that prejudices the plan's right of reimbursement. In order to secure the rights of the plan under this section, you or your dependent hereby: (1) grant to the plan a first priority lien against the proceeds of any such settlement, verdict or other amounts received by you or your dependent; and (2) assign to the plan any benefits you or your dependent may have under any automobile policy or other coverage, to the extent of the plan's claim for reimbursement. The reimbursement required under this provision will not be reduced to reflect any costs or attorneys' fees incurred in obtaining compensation unless separately agreed to, in writing, by the Plan Sponsor, in the exercise of its sole discretion. This plan expressly disavows and repudiates the make whole doctrine, which, if applicable, would prevent the plan from receiving a recovery unless a member has been 'made whole' with regard to illness or injury that is the responsibility of a third party. This plan also expressly disavows and repudiates the common fund doctrine, which, if applicable, would require the plan to pay a portion of the attorney fees and costs expended in obtaining a recovery. These doctrines have no application to this plan, since the plan's recovery rights apply to the first dollars payable by a third party. Subrogation This section applies whenever another party (including your own insurer under an automobile or other policy) is legally responsible or agrees to compensate you or your dependent for you or your dependent's illness or injury and the plan has paid benefits related to that illness or injury. The plan is subrogated to all of the rights of you or your dependent against any party liable for you or your dependent's illness or injury to the extent of the reasonable value of the benefits provided to you or your dependent under the plan. The plan may assert this right independently of you or your dependent. You and your dependent are obligated to cooperate with the plan and its authorized representatives in order to protect the plan's subrogation rights. Cooperation means providing the plan or its agents with any relevant information requested by them, signing and delivering such documents as the plan or its agents reasonably request to secure the plan's subrogation claim, and obtaining the consent of the plan or its agents before releasing any party from liability for payment of medical expenses. If you or your dependent enters into litigation or settlement negotiations regarding the obligations of other parties, you or your dependent must not prejudice, in any way, the subrogation rights of the plan under this section. The costs of legal representation of the plan in matters related to subrogation will be borne solely by the plan. The costs of legal representation of you or your dependent must be borne solely by you or your dependent. SPD 0714_City of Ashland Parks Final 72 Recovery of Excess Payments Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this plan, or were made in error by the plan, the plan has the right to recover these payments from any individual (including yourself), insurance company or other organization to whom the payments were made or to withhold payment, if necessary, on future benefits until the overpayment is recovered. If excess or erroneous payments were made for services rendered to your dependent(s), the plan has the right to withhold payment on your future benefits until the overpayment is recovered. Further, whenever payments have been made based on fraudulent information provided by you, the plan will exercise all available legal rights, including its right to withhold payment on future benefits, until the overpayment is recovered. In the same manner, if the plan applies medical expenses to the plan deductible that would not otherwise be reimbursable under the terms of this policy; the plan may deduct a like amount from the accumulated deductible amounts and/or recover payment of medical expenses that would have otherwise been applied to the deductible. The fact that a medical expense was applied to the plan's deductible, or that a drug was provided under the plan's prescription drug program, does not in itself create an eligible expense or infer that benefits will continue to be provided for an otherwise excluded condition. Right To Receive and Release Necessary Information The plan may, without the consent of or notice to any person, release to or obtain from any organization or person, information needed to implement plan provisions, including medical information. When you request benefits, you must either furnish or authorize the release of all the information required to implement plan provisions. Your failure to fully cooperate will result in a denial of the requested benefits and the plan will have no further liability for such benefits. Under normal conditions, benefits are payable to the provider of services or supplies, unless evidence of previous payment is submitted with the claim form. If conditions exist under which a valid release or assignment cannot be obtained, the plan may make payment to any individual or organization that has assumed the care or principal support for you and is equitably entitled to payment. The plan must make payments to your separated/divorced spouse, state child support agencies or Medicaid agencies if required by a qualified medical child support order (QMCSO) or state Medicaid law. The plan may also honor benefit assignments made prior to your death in relation to remaining benefits payable by the plan. Any payment made by the plan in accordance with this provision will fully release the plan of its liability to you. Reliance on Documents and Information Information required by the Plan Sponsor or PacificSource may be provided in any form or document that the Plan Sponsor and PacificSource considers acceptable and reliable. The Plan Sponsor and PacificSource relies on the information provided by you and others when evaluating coverage and benefits under the plan. All such information, therefore, must be accurate, truthful and complete. The Plan Sponsor and PacificSource is entitled to conclusively rely upon, and will be protected for any action taken in good faith in relying upon, any information provided to the Plan Sponsor or PacificSource. In addition, any fraudulent statement, omission or concealment of facts, misrepresentation, or incorrect information may result in the denial of the claim, cancellation or rescission of coverage, or any other legal remedy available to the plan. No Waiver The failure of the Plan Sponsor to enforce strictly any term or provision of this plan will not be construed as a waiver of such term or provision. The Plan Sponsor reserves the right to enforce strictly any term or provision of this plan at any time. Physician/Patient Relationship This plan is not intended to disturb the physician/patient relationship. Physicians, practitioners and other health care providers are not agents or delegates of the Plan Sponsor, or the Third Party Administrator. Nothing contained in this plan will require you or your dependent to commence or continue medical SPD 0714_City of Ashland Parks Final 73 treatment by a particular provider. Further, nothing in this plan will limit or otherwise restrict a physician or practitioner's judgment with respect to the physician or practitioner's ultimate responsibility for patient care in the provision of medical services to you or your dependent. Plan not responsible for Quality of Health Care You and your enrolled dependents have the right to select your health care provider. Neither the plan, your Plan Sponsor, nor Third Party Administrator is responsible for the quality of care received and cannot be held liable for any claim or damages connected with injuries suffered while receiving health services or supplies. Plan is not a Contract of Employment Nothing contained in this plan will be construed as a contract or condition of employment between the Plan Sponsor and any employee. All employees are subject to discharge to the same extent as if this plan had never been adopted. Right to Amend or Terminate Plan Plan Sponsor reserves the right to amend, modify or terminate the plan in any manner, for any reason, at any time. If changes occur, your Plan Sponsorwill notify you of changes to your plan. If your health plan terminates and your Plan Sponsor does not replace the coverage with another group policy, your Plan Sponsor is required by law to advise you in writing of the termination. When this plan terminates, your Plan Sponsorwill notify you about any available options for you to continue your coverage. The Plan Sponsor may pay your medical claims if a workers' compensation claim has been denied on the basis that the illness or injury is not work related, and the denial is under appeal. But before PacificSource does that, you must sign a written agreement to reimburse the Plan Sponsor any money you recover from the workers' compensation coverage. Rescissions The Plan Sponsor or PacificSource may not rescind the coverage of a member unless the member, or person seeking coverage on behalf of the member, performs an act, practice or omission that constitutes fraud or makes an intentional misrepresentation of a material fact as prohibited by the terms of this plan and the Plan Sponsor or PacificSource gives the member a 30-day prior written notice. PacificSource may not rescind the policyholder's group health benefit plan unless the policyholder, or representative of the policyholder, performs an act, practice or omission that constitutes fraud or makes an intentional misrepresentation of a material fact as prohibited by the terms of this plan and PacificSource gives a 30-day prior written notice to all member covered under the plan. Rescissions do not include a cancellation or discontinuance of coverage that is prospective or to the extent it is attributable to a failure to timely pay required contributions towards the cost of coverage. Applicable Law This is a self-insured benefit plan. As such, Federal law preempts State law and jurisdiction. To the extent not preempted by federal law, the laws of the state of Oregon shall apply. PRIVACY AND CONFIDENTIALITY This notice is intended to bring the City of Ashland Employee Benefit Plan into compliance with the requirements of Section 164.504(f) of the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, 45 C.F.R. parts 160 through 164 (the 'HIPAA Privacy Rule') by establishing the conditions under which the Plan Sponsorwill receive, use and/or disclose protected health information. Permitted Disclosures of Protected Health Information to the Plan Sponsor Subject to the conditions of the `No Disclosure of Protected Health Information to the Employer Without Certification by Employer' and `Conditions of Disclosure of Protected Health Information to the SPD 0714_City of Ashland Parks Final 74 Employer', the plan (and any third party administrator or business associate acting on behalf of the plan) may disclose individuals' protected health information to the Plan Sponsorfor the Plan Sponsor or PacificSource to carry out plan administration functions. The plan (and any third party administrator or business associate acting on behalf of the plan) may not disclose individuals' protected health information to the Plan Sponsor for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor. No Disclosure of Protected Health Information to the Plan Sponsorwithout Certification by Plan Sponsor Except as provided below in `Disclosures of Summary Health Information and Enroll ment/DisenrolIment Information to the Employer,' with respect to the plan's disclosure of summary health information and enroll ment/disenrollment information, the plan will not disclose protected health information to any employee of the Plan Sponsor. Conditions of Disclosure of Protected Health Information to the Plan Sponsor The Plan Sponsor certifies that the plan has been amended to incorporate this section and agrees to the following restrictions and conditions of receiving protected health information (other than summary health information or enrol lment/disenrollment information as explained in `Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the Plan Sponsor below). The Plan Sponsor shal I: • Not use or further disclose the protected health information other than as permitted or required herein or as required by law. • Ensure that any agent(s), including a subcontractor, to whom it provides protected health information received from the plan agrees to the same restrictions and conditions that apply to the Plan Sponsorwith respect to such protected health information. • Not use or disclose protected health information for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor. • Report to the plan any use or disclosure of protected health information that is inconsistent with the uses or disclosures provided for of which the Plan Sponsor becomes aware. • Make available protected health information to comply with an individual's right to access protected health information in accordance with 45 C.F.R. Section 164.524. • Make available protected health information for amendment and incorporate any amendments to protected health information in accordance with 45 C.F.R. Section 164.526. • Make available the information required to provide an accounting of disclosures in accordance with 45 C.F.R. §164.528. • Make its internal practices, books and records relating to the use and disclosure of protected health information received from the plan available to the Secretary of the Department of Health and Human Services for purposes of determining compliance by the plan with the HIPAA Privacy Rule. • If feasible, return or destroy all protected health information received from the plan that the Plan Sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, the Plan Sponsor will limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible. • Ensure that the required adequate separation, described in `Required Separation Between the Plan and the Plan Sponsor' below, is established and maintained. Disclosures of Summary Health Information and Enrollment/Disenrollment Information to the Plan Sponsor • The plan (or a third party administrator of the plan) may disclose summary health information to the Plan Sponsor without the need to comply with the conditions and restrictions of `No Disclosure of Protected Health Information to the Plan Sponsor Without Certification by Plan Sponsor' and `Conditions of Disclosure of Protected Health Information to the Plan Sponsor', if the Plan Sponsor requests the summary health information for the purpose of: - Obtaining premium bids from health plans (including health insurance issuers) for providing health insurance coverage under the plan; or SPD 0714_City of Ashland Parks Final 75 - Modifying, amending, or terminating the plan • The plan (or a third party administrator of the plan) may disclose information on whether the individual is participating in the group health plan, or is enrolled in or has disenrolled from the plan without the need to comply with the conditions and restrictions of 'No Disclosure of Protected Health Information to the Plan Sponsor Without Certification by Plan Sponsor' and 'Conditions of Disclosure of Protected Health Information to the Plan Sponsor' Required Separation between the Plan and the Plan Sponsor • The following classes of employees or other persons under the control of the Plan Sponsorwill have access to protected health information received from the plan (or from a health insurance issuer with respect to the plan): Human Resources • No other persons shall have access to protected health information. The listed classes of employees or other persons under the control of the Plan Sponsorwill have access to protected health information solely to perform the plan administration functions that the Plan Sponsor performs for the plan. They will be subject to disciplinary action and/or sanctions (including termination of employment or affiliation with the Plan Sponsor) for any use or disclosure of protected health information in violation of the provisions of this plan. DEFINITIONS Wherever used in this plan, the following definitions apply to the terms listed below, and the masculine includes the feminine and the singular includes the plural. For the purpose of this plan, `employee' includes the Plan Sponsorwhen covered by this plan. Other terms are defined where they are first used in the text. Abutment is a tooth used to support a prosthetic device (bridges, partials or overdentures). With an implant, an abutment is a device placed on the implant that supports the implant crown. Accident means an unforeseen or unexpected event causing injury that requires medical attention. Actively at work or active employment means that an employee is performing in the customary manner all of the regular duties of his/her occupation with the Plan Sponsor, either at one of the Plan Sponsor's regular places of business or at some location to which the Plan Sponsor's business requires the employee to travel to perform his/her regular duties assigned by the Plan Sponsor. An employee is also considered to be actively at work on each day of a regular paid vacation or non-work day, but only if the employee is performing in the customary manner all of the regular duties of the employee's occupation with the Plan Sponsor on the immediately preceding regularly scheduled workday. Advanced diagnostic imaging means diagnostic examinations using CT scans, MRIs, PET scans, CATH labs, and nuclear cardiology studies. Adverse benefit determination means a denial, reduction, or termination of a healthcare item or service, or a failure or refusal to provide or to make a payment in whole or in part for a healthcare item or service, that is based on the Plan Sponsor's or PacificSource's: • Denial of eligibility for or termination of enrollment in a health benefit plan; • Rescission or cancellation of a policy or coverage; • Imposition of a source-of-injury exclusion, network exclusion, annual benefit limit or other limitation on otherwise covered items or services; • Determination that a healthcare item or service is experimental, investigational, or not medically necessary, effective, or appropriate; or • Determination that a course or plan of treatment that a member is undergoing it an active course of treatment for purposes of continuity of care under ORS 743.854. Advantage Essential Network is the exclusive provider network that provides dental care to members under this plan. Allowable fee is the dollar amount established by the plan for reimbursement of charges for specific services or supplies provided by nonparticipating providers. The plan uses several sources to determine the allowable amount. Depending on the service or supply and the geographical area in which it is provided, the allowable amount may be based on data collected from the Centers for SPD 0714_City of Ashland Parks Final 76 Medicare and Medicaid Services (CMS), Viant Health Payment Solutions, other nationally recognized databases, or PacificSource. Where the provider network is deemed adequate, the allowable fee for professional services is based on PacificSource's standard participating provider reimbursement rate or a contracted reimbursement rate. Outside the PacificSource service area and in areas where the participating provider network is not deemed adequate, the allowable fee is based on the usual, customary, and reasonable charge (UCR) at the 85th percentile. UCR is based on data collected for a geographic area. Provider charges for each type of service are collected and ranked from lowest to highest. Charges at the 85th position in the ranking are considered to be the 85th percentile. Alveolectomy is the removal of bone from the socket of a tooth. Amalgam is a silver-colored material used in restoring teeth. Ambulatory surgical center means a facility licensed by the appropriate state or federal agency to perform surgical procedures on an outpatient basis. Ancillary Services means service rendered in connection with Inpatient or Outpatient care in a Hospital or in connection with a medical emergency, such as assistant surgeon, anesthesiology, ambulance, pathology and radiology. Approved clinical trials are Phase I, II, III, or IV clinical trials for the prevention, detection, or treatment of cancer or another life-threatening condition or disease. Authorized representative is an individual who by law or by the contest of a person may act on behalf of the person. Benefit year means the 12-month period beginning on each January 1 and ending on the next December 31. Cardiac rehabilitation refers to a comprehensive program that generally involves medical evaluation, prescribed exercise, and cardiac risk factor modification. Education, counseling, and behavioral interventions are sometimes used as well. Phase I refers to inpatient services that typically occur during hospitalization for heart attack or heart surgery. Phase II refers to a short-term outpatient program, usually involving ECG-monitored exercise. Phase III refers to a long-term program, usually at home or in a community-based facility, with little or no ECG monitoring. Cast restoration includes crowns, inlays, onlays, and other restorations made to fit a patient's tooth that are made at a laboratory and cemented onto the tooth. Certificate of Creditable Coverage means a certificate or other documentation that shows previous health insurance coverage for a member and can be used to reduce the length of any pre-existing condition exclusions under a plan. See Creditable coverage. Chemical dependency means the addictive relationship with any drug or alcohol characterized by either a physical or psychological relationship, or both, that interferes with the individual's social, psychological, or physical adjustment to common problems on a recurring basis. Chemical dependency does not include addiction to, or dependency on, tobacco products or foods. Claims Administrator means the organization selected by the City of Ashland to provide claims processing and adjudication under their plans. The Claims Administrator for their medical, vision and pharmacy coverage is PacificSource. Composite resin is a tooth-colored material used in restoring teeth. Contracted amount means the amount that participating providers have contracted to accept as payment in full for covered expenses under the plan. Co-payment or co-insurance is the out-of-pocket amount a member is required to pay to a provider. Creditable coverage means a member's prior health coverage that meets the following criteria: • There was no more than a 63-day break between the last day of coverage under the previous policy and the first day of coverage under this policy. The 63-day limit excludes the Plan Sponsor's eligibility waiting period. • The prior coverage was one of the following types of insurance: group coverage (including Federal Employee Health Benefit Plans and Peace Corps), individual coverage (including student health plans), Medicaid, Medicare, TRICARE, Indian Health Service or tribal organization coverage, state high-risk pool coverage, and public health plans. Curettage is the scraping and cleaning of the walls of a real or potential space, such as a gingival pocket or bone, to remove pathological material. SPD 0714_City of Ashland Parks Final 77 Custodial Care means non-medical care that is primarily to assist with activities of daily living, whether or not the care is administered by a licensed provider. Deductible means the portion of the healthcare expense that must be paid by the member before the benefits of this plan are applied. Dental emergency means the sudden and unexpected onset of a condition, or exacerbation of an existing condition, requiring necessary care to control pain, swelling or bleeding in or around the teeth and gums. Such emergency care must be provided within 48 hours following the onset of the emergency and includes treatment for acute infection, pain, swelling, bleeding, or injury to natural teeth and oral structures. The emergency care does not include follow-up care such as, but not limited to, crowns, root canal therapy, or prosthetic benefits. Dentist means a person acting within the scope of their license, holding the degree of Doctor of Medicine (M.D.), Doctor of Dental Surgery (D.D.S.), or Doctor of Dental Medicine (D.M.D.), and who is legally entitled to practice dentistry in all its branches under the laws of the state or jurisdiction where the services are rendered. Durable medical equipment means equipment that can withstand repeated use; is primarily and customarily used to serve a medical purpose rather than convenience or comfort; is generally not useful to a person in the absence of an illness or injury; is appropriate for use in the home; and is prescribed by a physician. Examples of durable medical equipment include but are not limited to hospital beds, wheelchairs, crutches, canes, walkers, nebulizers, commodes, suction machines, traction equipment, respirators, TENS units, and hearing aids. Durable medical equipment supplier means a PacificSource contracted provider or a provider that satisfies the criteria in the Medicare Qualify Standards for Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) and Other Items and Services Summary Plan Description. Elective surgery or procedure refers to a surgery or procedure for a condition that does not require immediate attention and for which a delay would not have a substantial likelihood of adversely affecting the health of the patient. Eligible dental provider means a physician, dentist, oral surgeon, endodontist, orthodontist, periodontist, or pedodontist. Eligible provider may also include a denturist or dental hygienist to the extent that he/she operates within the scope of their license. Emergency medical condition means a medical condition: • That manifests itself by acute symptoms of sufficient severity, including severe pain that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would: - Place the health of a person, or an unborn child in the case of a pregnant woman, in serious jeopardy; - Result in serious impairment to bodily functions; or - Result in serious dysfunction of any bodily organ or part; or • With respect to a pregnant woman who is having contractions, for which there is inadequate time to affect a safe transfer to another hospital before delivery or for which a transfer may pose a threat to the health or safety of the woman or the unborn child. Emergency medical screening exam means the medical history, examination, ancillary tests, and medical determinations required to ascertain the nature and extent of an emergency medical condition Emergency services means, with respect to an emergency medical condition: • An emergency medical screening exam that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and • Such further medical examination and treatment as are required under 42 U.S.C. 1395dd to stabilize the patient to the extent the examination and treatment are within the capability of the staff and facilities available at a hospital. Employee means any individual employed by a Plan Sponsor. Endorsement is a written attachment that alters and supersedes any of the terms or conditions set forth in this contract. Enrollee means an employee, dependent of the employee, or individual otherwise eligible and enrolled for coverage under this plan. In this policy, enrollee is referred to as subscriber or member. SPD 0714_City of Ashland Parks Final 78 Essential health benefits are services defined as such by the Secretary of the U.S. Department of Health and Human Services. Essential health benefits fall into the following categories: • Ambulatory patient services; • Emergency services; • Hospitalization; • Maternity and newborn care; • Mental health and substance use disorder services, including behavioral health treatment; • Prescription drugs; • Rehabilitative and habilitative services and devices; • Laboratory services; • Preventive and wellness services and chronic disease management; and • Pediatric services, including oral and vision care. Exclusion period means a period during which specified conditions, treatments or services are excluded from coverage. Experimental or investigational procedures means services, supplies, protocols, procedures, devices, chemotherapy, drugs or medicines, or the use thereof, that are experimental or investigational for the diagnosis and treatment of illness or injury. • Experimental or investigational services and supplies include, but are not limited to, services, supplies, procedures, devices, chemotherapy, drugs or medicines, or the use thereof, which at the time they are rendered and for the purpose and in the manner they are being used: - Have not yet received full U.S. government agency required approval (e.g., FDA) for other than experimental, investigational, or clinical testing; Are not of generally accepted medical practice in the state of Oregon or as determined by PacificSource in consultation with medical advisors, medical associations, and/or technology resources; - Are not approved for reimbursement by the Centers for Medicare and Medicaid Services, - Are furnished in connection with medical or other research; or - Are considered by any governmental agency or subdivision to be experimental or investigational, not considered reasonable and necessary, or any similar finding. • When making decisions about whether treatments are investigational or experimental, PacificSource relies on the above resources as well as: - Expert opinions of specialists and other medical authorities; - Published articles in peer-reviewed medical literature; External agencies whose role is the evaluation of new technologies and drugs; and External review by an independent review organization. • The following will be considered in making the determination whether the service is in an experimental and/or investigational status: Whether there is sufficient evidence to permit conclusions concerning the effect of the services on health outcomes; Whether the scientific evidence demonstrates that the services improve health outcomes as much or more than established alternatives; Whether the scientific evidence demonstrates that the services' beneficial effects outweigh any harmful effects; and Whether any improved health outcomes from the services are attainable outside an investigational setting. Formulary is a list of approved brand name medications used to treat various medical conditions. The formulary list is developed by the pharmacy benefits management company and PacificSource. Generic drugs are drugs that, under federal law, require a prescription by a licensed physician (M.D. or D.O.) or other licensed medical provider and are not a brand name medication. By law, generic drugs SPD 0714_City of Ashland Parks Final 79 must have the same active ingredients as the brand name medication and are subject to the same standards of their brand name counterpart. Grievance means: • A request submitted by a member or an authorized representative of a member; In writing, for an internal appeal or an external review; or - In writing or orally, for an expedited internal review or an expedited external review; or • A written complaint submitted by a member or an authorized representative of a member regarding: - The availability, delivery, or quality of a healthcare service; Claims payment, handling, or reimbursement for healthcare services and, unless the member has not submitted a request for an internal appeal, the complaint is not disputing an adverse benefit determination; or Matters pertaining to the contractual relationship between a member and PacificSource. Health care provider means a physician, practitioner, nurse, hospital or specialized treatment facility as defined in this document. Health benefit plan means any hospital expense, medical expense, or hospital or medical expense policy or certificate, healthcare contractor or health maintenance organization subscriber contract, or any plan provided by a multiple employer welfare arrangement or by another benefit arrangement defined in the federal Employee Retirement Income Security Act of 1974, as amended, to the extent that plan is subject to state regulation. Hearing aids mean any non-disposable, wearable instrument or device designed to aid or compensate for impaired human hearing and any necessary ear mold, part, attachments or accessory for the instrument or device, except batteries and cords. Hearing aids include any amplifying device that does not produce as its output an electrical signal that directly stimulates the auditory nerve. For the purpose of this definition, such amplifying devices include air conduction and bone conduction devices, as well as those that provide vibratory input to the middle ear. Homebound means the ability to leave home only with great difficulty with absences infrequently and of short duration. Infants and toddlers will not be considered homebound without medical documentation that clearly establishes the need for home skilled care. Lack of transportation is not considered sufficient medical criterion for establishing that a person is homebound. Hospital means an institution licensed as a `general hospital' or `intermediate general hospital' by the appropriate state agency in the state in which it is located. Illness includes a physical or mental condition that results in a covered expense. Physical illness is a disease or bodily disorder. Mental illness is a psychological disorder that results in pain or distress and substantial impairment of basic or normal functioning. Incurred expense means charges of a healthcare provider for services or supplies for which a member becomes obligated to pay. The expense of a service is incurred on the day the service is rendered, and the expense of a supply is incurred on the day the supply is delivered. Initial enrollment period means a period of 60 days following the date an individual is first eligible to enroll. Injury means bodily trauma or damage that is independent of disease or infirmity. The damage must be caused solely by external and accidental means and does not include muscular strain sustained while performing a physical activity. Inquiry means a written request for information or clarification about any subject matter related to the member's health benefit plan. Internal appeal means a review by PacificSource or your Plan Sponsor of an adverse benefit determination made by PacificSource. Leave of absence is a period of time off work granted to an employee by the Plan Sponsor at the employee's request and during which the employee is still considered to be employed and is carried on the employment records of the Plan Sponsor. A leave can be granted for any reason acceptable to the Plan Sponsor, including disability and pregnancy. Lifetime means the period of time a member is enrolled in this plan or any other Plan Sponsored by the Plan Sponsor. SPD 0714_City of Ashland Parks Final 80 Mastectomy is the surgical removal of all or part of a breast or a breast tumor suspected to be malignant. Medically necessary means those services and supplies that are required for diagnosis or treatment of illness or injury and that are: • Consistent with the symptoms or diagnosis and treatment of the condition; • Consistent with generally accepted standards of good medical practice in the state of Oregon, or expert consensus physician opinion published in peer-reviewed medical literature, or the results of clinical outcome trials published in peer-reviewed medical literature; • As likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any other service or supply, both as to the disease or injury involved and the patient's overall health condition; • Not for the convenience of the member or a provider of services or supplies; • The least costly of the alternative services or supplies that can be safely provided. When specifically applied to a hospital inpatient, it further means that the services or supplies cannot be safely provided in other than a hospital inpatient setting without adversely affecting the patient's condition or the quality of medical care rendered. Services and supplies intended to diagnose or screen for a medical condition in the absence of signs or symptoms, or of abnormalities on prior testing, including exposure to infectious or toxic materials or family history of genetic disease, are not considered medically necessary under this definition (see General Exclusions - Screening tests). Medical supplies means items of a disposable nature that may be essential to effectively carry out the care a physician has ordered for the treatment or diagnosis of an illness or injury. Examples of medical supplies include but are not limited to syringes and needles, splints and slings, ostomy supplies, sterile dressings, elastic stockings, enteral foods, drugs or biologicals that must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment or to assure the proper functioning of this equipment (e.g. Albuterol for use in a nebulizer). Member means an individual insured through the Plan Sponsor. Mental and/or chemical healthcare facility means a corporate or governmental entity or other provider of services for the care and treatment of chemical dependency and/or mental or nervous conditions which is licensed or accredited by the Joint Commission on Accreditation of Hospitals or the Commission on Accreditation of Rehabilitation Facilities for the level of care which the facility provides. Mental and/or chemical healthcare program means a particular type or level of service that is organizationally distinct within a mental and/or chemical healthcare facility. Mental and/or chemical healthcare provider means a person that has met the credentialing requirements of PacificSource, is otherwise eligible to receive reimbursement under the policy and is: • A healthcare facility where appropriately licensed or accredited by the Commission on Accreditation of Hospitals or the Commission on Accreditation of Rehabilitation Facilities; • A residential program or facility; • A day or partial hospitalization program; • An outpatient service; or • An individual behavioral health or medical professional authorized for reimbursement under Oregon law. Mental or nervous conditions means all disorders listed in the `Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, Fourth Edition' except for: • Mental Retardation (diagnostic codes 317, 318.0, 318.1, 318.2, 319); • Learning Disorders (diagnostic codes 315.00, 315.1, 315.2, 315.9); • Paraphilias (diagnostic codes 302.4, 302.81, 302.89, 302.2, 302.83, 302.84, 302.82, 302.9); and • Gender Identity Disorders in Adults (diagnostic codes 302.85, 302.6, 302.9 - this exception does not extend to children and adolescents 18 years of age or younger); and • `V' codes (diagnostic codes V15.81 through V71.09 - this exception does not extend to children five years of age or younger for diagnostic codes V61.20, V61.21, and V62.82). SPD 0714_City of Ashland Parks Final 81 Network not available means a member does not have reasonable geographic access to a PacificSource participating provider for a medical service or supply. Non-participating provider is a provider of covered medical services or supplies that does not directly or indirectly hold a provider contract or agreement with PacificSource. Non-preferred drugs are covered brand name medications not on the Preferred Drug List. Orthotic devices means rigid or semirigid devices supporting a weak or deformed leg, foot, arm, hand, back or neck or restricting or eliminating motion in a diseased or injured leg, foot, arm, hand, back or neck. Benefits for orthotic devices include orthopedic appliances or apparatus used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body. An orthotic device differs from a prosthetic in that, rather than replacing a body part, it supports and/or rehabilitates existing body parts. Orthotic devices are usually customized for an individual's use and are not appropriate for anyone else. Examples of orthotic devices include but are not limited to Ankle Foot Orthosis (AFO), Knee Ankle Foot Orthosis (KAFO), Lumbosacral Orthosis (LSO), and foot orthotics. PacificSource refers to PacificSource Health Plans. PacificSource is the claims administrator of the Plan Sponsors medical, vision and pharmacy coverage. References to PacificSource as paying claims or issuing benefits means that PacificSource processes a claim in accordance with the provisions of the Plan Sponsors plans. Participating provider means a physician, healthcare professional, hospital, medical facility, or supplier of medical supplies that directly or indirectly holds a provider contract or agreement with the plan. Periapical x-ray is an x-ray of the area encompassing or surrounding the tip of the root of a tooth. Periodontal maintenance is a periodontal procedure for patients who have previously been treated for periodontal disease. In addition to cleaning the visible surfaces of the teeth (as in prophylaxis) surfaces below the gum-line are also cleaned. This is a more comprehensive service than a regular cleaning (prophylaxis). Periodontal scaling and root planing means the removal of plaque and calculus deposits from the root surface under the gum line. Physical/occupational therapy is comprised of the services provided by (or under the direction and supervision of) a licensed physical or occupational therapist. Physical/occupational therapy includes emphasis on examination, evaluation, and intervention to alleviate impairment and functional limitation and to prevent further impairment or disability. Physician means a state-licensed Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.). Physician assistant is a person who is licensed by an appropriate state agency as a physician assistant. Plan means the City of Ashland Employee Benefits Plan, and all documents, including any contracts, administrative service agreements, Summary Plan Descriptions and any related terms and conditions associated with the Plan. Plan Administrator means the Risk Services Division of the City of Ashland, which has responsibility for the management of the plan. Plan Sponsor (`the Plan Sponsor' or `your Plan Sponsor'), means the City of Ashland. The City of Ashland is the fiduciary of the plan, and exercises all discretionary authority and control over the administration of the plan and the management and disposition of plan assets. The Plan Sponsorshall have the sole discretionary authority to determine eligibility for plan benefits or to construe the terms of the plan, and benefits under the plan will be paid only if the Plan Sponsor decides, in its discretion, that the member or beneficiary is entitled to such benefits. The Plan Sponsor has the right to amend, modify, or terminate the plan in any manner, at any time, regardless of the health status of any plan member or beneficiary. Practitioner means Doctor or Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Dental Medicine (D.M.D.), Doctor of Podiatry Medicine (D.P.M.), Doctor of Chiropractic (D.C.), Doctor of Optometry (O.D.), Licensed Nurse Practitioner (including Certified Nurse Midwife (C.N.M.) and Certified Registered Nurse Anesthetist (C.R.N.A.)), Registered Physical Therapist (R.P.T.), Speech Therapist, Occupational Therapist, Psychologist (Ph.D.), Licensed Clinical Social Worker (L.C.S.W.), Licensed Professional Counselor (L.P.C.), Licensed Marriage and Family Therapist (LMFT), Licensed Psychologist Associate (LPA), Physician Assistant (PA), Audiologist, Acupuncturist, Naturopathic Physician, and Licensed Massage Therapist. SPD 0714_City of Ashland Parks Final 82 Pre-existing condition means a condition (physical or mental) for which medical advice, diagnosis, care, or treatment was recommended by or received from a licensed provider within the six-month period ending on the enrollment date. For the purpose of this definition, the enrollment date of a member is the earlier of the effective date of coverage or the first day of any required group eligibility waiting period, and the enrollment date of a late enrollee is the effective date of coverage. Pregnancy does not constitute a pre-existing condition, nor does genetic information without a diagnosis of a condition related to such information. Preferred is a list of approved brand name medications used to treat various medical conditions. The Preferred Drug List is developed by the pharmacy benefits management company and PacificSource. Prescription drugs are drugs that, under federal law, require a prescription by a licensed physician (M.D. or D.O.) or other licensed medical provider. Prophylaxis is a cleaning and polishing of all teeth. Prosthetic devices (excluding dental) means artificial limb devices or appliances designed to replace in whole or in part an arm or a leg. Benefits for prosthetic devices include coverage of devices that replace all or part of an internal or external body organ, or replace all or part of the function of a permanently inoperative or malfunctioning internal or external organ, and are furnished on a physician's order. Examples of prosthetic devices include but are not limited to artificial limbs, cardiac pacemakers, prosthetic lenses, breast prosthesis (including mastectomy bras), and maxillofacial devices. Pulpotomy is the removal of a portion of the pulp, including the diseased aspect, with the intent of maintaining the vitality of the remaining pulpal tissue by means of a therapeutic dressing. Qualified domestic partner means a registered domestic partner or unregistered same gender domestic partner with an Affidavit of Domestic Partnership, supplied by the Plan Sponsor. Restoration is the treatment that repairs a broken or decayed tooth. Restorations include, but are not limited to, fillings and crowns. Routine costs of care means medically necessary conventional care, items, or services covered by the health benefit plan if typically provided absent a clinical trial. Routine costs of care do not include: • The drug, device, or service being tested in the clinical trial unless the drug, device, or service would be covered for that indication by the policy if provided outside of a clinical trial; • Items or services required solely for the provisions of the drug, device, or service being tested in the clinical trial; • Items or services required solely for the clinically appropriate monitoring of the drug, device, or service being tested in the clinical trial; • Items of services required solely for the prevention, diagnosis, or treatment of complications arising from the provision of the drug, device, or service being tested in the clinical trial; • Items or services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient; • Items or services customarily provided by a clinical trial sponsor free of charge to any participant in the clinical trial; or • Items or services that are not covered by the policy if provided outside of the clinical trial. Seasonal employee is an employee who is hired with the agreement that their employment will end after a predetermined period of time. Skilled nursing facility convalescent home means an institution that provides skilled nursing care under the supervision of a physician, provides 24-hour nursing service by or under the supervision of a registered nurse (R.N.), and maintains a daily record of each patient. Skilled nursing facilities must be licensed by an appropriate state agency and approved for payment of Medicare benefits to be eligible for reimbursement. Specialized treatment facility means a facility that provides specialized short-term or long-term care. The term specialized treatment facility includes ambulatory surgical centers, birthing centers, chemical dependency/substance abuse day treatment facilities, hospice facilities, inpatient rehabilitation facilities, mental and/or chemical healthcare facilities, organ transplant facilities, psychiatric day treatment facilities, residential treatment facilities, skilled nursing facilities, substance abuse treatment facilities, and urgent care treatment facilities. Specialty drugs are high dollar oral, injectable, infused or inhaled biotech medications prescribed for the treatment of chronic and/or genetic disorders with complex care issues that have to be managed. SPD 0714_City of Ashland Parks Final 83 The major conditions these drugs treat include but are not limited to: cancer, HIV/AIDS, hemophilia, hepatitis C, multiple sclerosis, Crohn's disease, rheumatoid arthritis, and growth hormone deficiency. Specialty pharmacies specialize in the distribution of specialty drugs and providing pharmacy care management services designed to assist patients in effectively managing their condition. Stabilize means to provide medical treatment as necessary to ensure that, within reasonable medical probability, no material deterioration of an emergency medical condition is likely to occur during or to result from the transfer of the patient from a facility; and with respect to a pregnant woman who is in active labor, to perform the delivery, including the delivery of the placenta. Subscriber means an employee or former employee insured under the Plan Sponsor's health policy through PacificSource. When a family unit that does not include an employee or former employee is insured under a policy, the oldest family member is referred to as the subscriber. Surgical procedure means any of the following operative procedures: • Procedures accomplished by cutting or incision • Suturing of wounds • Treatment of fractures, dislocations, and burns • Manipulations under general anesthesia • Visual examination of the hollow organs of the body including biopsy, or removal of tumors or foreign body • Procedures accomplished by the use of cannulas, needling, or endoscopic instruments • Destruction of tissue by thermal, chemical, electrical, laser, or ultrasound Telemedical means medical services delivered through a two-way video communication that allows a provider to interact with a patient who is at a different physical location than the provider. Temporomandibular Joint Disorder (TMJ) means any dysfunction or disorder of the jaw joint resulting in pain and impairment of the jaw. Third Party Administrator is an administrator hired by the Plan Sponsorto perform claims processing and other specified administrative services in relation to the plan. The third party administrator is not an insurer of health benefits under this plan, is not a fiduciary of the plan, and does not exercise any of the discretionary authority and responsibility granted to the Plan Sponsor. The third party administrator is not responsible for plan financing and does not guarantee the availability of benefits under this plan. The third party administrator is PacificSource Health Plans Tobacco use cessation program means a program recommended by a physician that follows the United States Public Health Services guidelines for tobacco use cessation. Tobacco use cessation program includes education and medical treatment components designed to assist a person in ceasing the use of tobacco products. Unregistered domestic partner means an individual of the same-gender who is joined in a domestic partnership with the subscriber and meets the following criteria: • Is at least 18 years of age; • Not related to the policyholder by blood closer than would bar marriage in Oregon or the state where they have permanent residence and are domiciled; • Shares jointly the same permanent residence with the policyholder for at least six months immediately preceding the date of application to enroll and intent to continue to do so indefinitely; • Has joint financial accounts with the policyholder and has agreed to be jointly responsible with the policyholder for each other's common welfare, including basic living expenses; • Has an exclusive domestic partnership with the policyholder and has no other domestic partner; • Does not have a legally binding marriage nor has had another domestic partner within the previous six months; • Was mentally competent to consent to contract when the domestic partnership began and remains mentally competent. Urgent care treatment facility means a healthcare facility whose primary purpose is the provision of immediate, short-term medical care for minor, but urgent, medical conditions. SPD 0714_City of Ashland Parks Final 84 Waiting period means the period of time before coverage becomes effective for a memberwho is otherwise eligible to enroll in the plan. Women's healthcare provider means an obstetrician, gynecologist, physician assistant or nurse practitioner specializing in women's health, or certified nurse midwife practicing within the applicable scope of practice. RIGHTS OF PLAN MEMBERS MEDICAID AND CHIP STATE CONTACT INFORMATION If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your Plan Sponsor, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health coverage through their Plan Sponsor. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for a Plan Sponsor-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your Plan Sponsor plan, your Plan Sponsor must permit you to enroll in your Plan Sponsor plan if you are not already enrolled. This is called a 'special enrollment' opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your Plan Sponsor plan, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA (3272). If you live in one of the following States, you may be eligible for assistance paying your Plan Sponsor health plan premiums. The following list of States is current as of July 31, 2012. You should contact your State for further information on eligibility - ALABAMA - Medicaid COLORADO - Medicaid Website: http://www.medicaid.alabama.gov Medicaid Website: http://www.colorado.gov/ Phone: 1-855-692-5447 Medicaid Phone (In state): 1-800-866-3513 ALASKA - Medicaid Medicaid Phone (Out of state): 1-800-221-3943 Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 ARIZONA - CHIP FLORIDA - Medicaid Website: http://www.azahcccs.gov/applicants Website: https://www.fimedicaidtp]recovery.com/ Phone (Outside of Maricopa County): 1-877-764-5437 Phone: 1-877-357-3268 Phone (Maricopa County): 602-417-5437 GEORGIA - Medicaid Website: http://dch.georgia.gov/ Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150 IDAHO - Medicaid and CHIP MONTANA - Medicaid Medicaid Website: Website: www.accesstohealthinsurance.idaho.gov http://medicaidprovider.hhs.mt.gov/clientpages/ Medicaid Phone: 1-800-926-2588 clientindex.shtml CHIP Website: www.medicaid.idaho.gov Phone: 1-800-694-3084 CHIP Phone: 1-800-926-2588 INDIANA - Medicaid NEBRASKA - Medicaid Website: http://www.in.gov/fssa Website: www.ACCESSNebraska.ne.gov Phone: 1-800-889-9949 Phone: 1-800-383-4278 SPD 0714_City of Ashland Parks Final 85 IOWA - Medicaid NEVADA - Medicaid Website: www.dhs.state.ia.us/hipp/ Medicaid Website: http://dwss.nv.gov/ Phone: 1-888-346-9562 Medicaid Phone: 1-800-992-0900 KANSAS - Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884 KENTUCKY - Medicaid NEW HAMPSHIRE - Medicaid Website: http://chfs.ky.gov/dms/default.htm Website: Phone: 1-800-635-2570 http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 LOUISIANA - Medicaid NEW JERSEY - Medicaid and CHIP Website: http://www.lahipp.dhh.louisiana.gov Medicaid Website: Phone: 1-888-695-2447 http://www.state.nj.us/humanservices/ MAINE- Medicaid dmahs/clients/medicaid/ Website: http://www.maine.gov/dhhs/ofi/public- Medicaid Phone: 1-800-356-1561 assistance/index.html CHIP Website: Phone: 1-800-977-6740 http://www.njfamilycare.org/index.html TTY 1-800-977-6741 CHIP Phone: 1-800-701-0710 MASSACHUSETTS - Medicaid and CHIP NEW YORK - Medicaid Website: http://www.mass.gov/MassHealth Website: Phone: 1-800-462-1120 http://www.nyhealth.gov/health-care/medicaid/ Phone: 1-800-541-2831 MINNESOTA - Medicaid NORTH CAROLINA - Medicaid Website: http://www.dhs.state.mn.us/ Website: http://www.ncdhhs.gov/dma Click on Health Care, then Medical Assistance Phone: 919-855-4100 Phone: 1-800-657-3629 MISSOURI - Medicaid NORTH DAKOTA - Medicaid Website: Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.ht http://www.nd.gov/dhs/services/medicalserv/medicai m d/ Phone: 573-751-2005 Phone: 1-800-755-2604 OKLAHOMA - Medicaid and CHIP UTAH - Medicaid and CHIP Website: http://www.insureoklahoma.org Website: http://health.utah.gov/upp Phone: 1-888-365-3742 Phone: 1-866-435-7414 OREGON - Medicaid and CHIP VERMONT- Medicaid Website: http://www.oregonhealthykids.gov Website: http://www.greenmountaincare.org/ http://www.hijossaludablesoregon.gov Phone: 1-800-250-8427 Phone: 1-877-314-5678 PENNSYLVANIA - Medicaid VIRGINIA - Medicaid and CHIP Website: http://www.dpw.state.pa.us/hipp Medicaid Website: http://www.dmas.virginia.gov/rcp- Phone: 1-800-692-7462 H I P P. htm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.famis.org/ CHIP Phone: 1-866-873-2647 RHODE ISLAND - Medicaid WASHINGTON - Medicaid Website: www.ohhs.ri.gov Website: Phone: 401-462-5300 http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm Phone: 1-800-562-3022 ext. 15473 SOUTH CAROLINA - Medicaid WEST VIRGINIA - Medicaid Website: http://www.scdhhs.gov Website: www.dhhr.wv.gov/bms/ Phone: 1-888-549-0820 Phone: 1-877-598-5820, HMS Third Part Liability SOUTH DAKOTA - Medicaid WISCONSIN - Medicaid Website: http://dss.sd.gov Website: http://www.badgercareplus.org/pubs/p- Phone: 1-888-828-0059 10095. htm Phone: 1-800-362-3002 TEXAS - Medicaid WYOMING - Medicaid Website: https://www.gethipptexas.com/ Website: Phone: 1-800-440-0493 http://health.wyo.gov/healthcarefin/equalitycare Phone: 307-777-7531 SPD 0714_City of Ashland Parks Final 86 To see if any more States have added a premium assistance program since July 31, 2012, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health & Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cros.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565 OMB Control Number 1210-0137 (expires 09/30/2013) SPD 0714_City of Ashland Parks Final 87 PLAN INFORMATION Name and Address of the Plan Sponsor City of Ashland 20 East Main Ashland, OR 97520 (541) 488-6002 Name and Address of the Designated Agent for Service of Legal Process Dave Kanner, City Administrator 20 East Main Ashland, OR 97520 541-488-6002 Name and Address of the Third Party Administrator PacificSource Health Plans PO Box 7068 Springfield, OR 97475-0068 (888) 977-9299 Fax: (541) 684-5264 cs@pacificsource.com Internal Revenue Service and Plan Identification Number The corporate tax identification number assigned by the Internal Revenue Service is 936002117. The plan number is 501. Benefit Year The benefit year is the 12-month period of time beginning January 1 and ending December 31. Method of Funding Benefits Health benefits are self-insured from the general assets and or trust funds of the Plan Sponsor and are not guaranteed under an insurance policy or contract. The Plan Sponsor may purchase excess risk insurance coverage which is intended to reimburse the Plan Sponsorfor certain losses incurred and paid under the plan by the Plan Sponsor. Such excess risk coverage, if any, is not part of the plan. The cost of the plan is paid with contributions by the Plan Sponsor and participating employees. The Plan Sponsor determines the amount of contributions to the plan, based on estimates of claims and administration costs. Payments out of the plan to health care providers on behalf of the covered person will be based on the provisions of the plan. SPD 0714_City of Ashland Parks Final 88 This page left intentionally blank. SPD 0714_City of Ashland Parks Final 89 SIGNATURE PAGE The effective date of the Preferred 90+200 VAR GF 0812 plan is July 1, 2014. It is agreed by the City of Ashland that the provisions of this document are correct and will be the basis for the administration of the Preferred 90+200 VAR GF 0812 plan. Dated this day of By Title SPD 0714_City of Ashland Parks Final 90 This page left intentionally blank. SPD 0714_City of Ashland Parks Final 91 co CG ~a C- co N 0 0 9 G N On U c6 N N N O- .O G O ~ Q N d U p C ~ N U cb r 7i -6 N O N aj ~ R ~ N ~ a) N O tc6 9 V O o U Q- Ef) O i, N N p G p N U LO O r t5 cTb CS) N n ° w Qc Em a c6~GJ ~1 O d G ✓ y t -0) O Q R 7 E N U J 3 > G i d V D- cb N U OJ (d a) CS) 30 a m 0 (n N S 0 4 N N R O ° G J LSD G. 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N - T N Q• O C N [4 "T_ 0 = 0 0) 0, C- s G N N T O 07 U N '6 ° 9 N N C7o~o N~ n~~ in c) in 0 W N° r a~ v w Q°~ c~ N ° rc o N~ v ca 6 o c Q 3 m m m a co ° ca ° o u c) 0) co O 10) ti 0-0 ? Cq Q U N O R U 2 N N o f w~ m m Q N o- co uA U 0 4 5 u d m U m° K o O N ) ° o Q O ° CO W Q S O J O ~ ~ cll O V .y R V d .t N E a. CITY OF ASHLAND Council Communication June 2, 2015, Business Meeting Community Climate and Energy Action Plan Ad-Hoc Committee Formation Request FROM: Adam Hanks, Management Analyst, Administration - adam@ashland.or.us SUMMARY At the March 16, 2015 Council study session, the Conservation Commission, through its Climate/Energy sub-committee, presented a plan framework for a community climate action and energy plan. As a stated follow-up task, the Commission is requesting that Council approve the formation of an ad-hoc committee. Approving the creation of this ad-hoc committee is a key initial step in moving the project from concept framework to active plan development and begins the process of seeking interested community members to contact the Mayor for his appointments tentatively scheduled to be announced and confirmed at a future Council meeting in late July or early August. BACKGROUND AND POLICY IMPLICATIONS: The Conservation Commission has for some time been interested in the City increasing its in the area of sustainability and has spent many years working on both individual sustainability related projects as well as the development and approval of broad policy level sustainability principles for City and community decision making. Climate Action and Energy Plan (CAEP) - Current Status The Commission's most recent work culminated in a presentation to the Council on March 16, 2015, outlining a process and content framework for a community climate action and energy plan. Along with and central to the Commission's request to move forward with such a community plan was a funding request to move the plan from concept to reality. The funding request of $120,000 over the 2015-17 biennium was approved by the Citizen's Budget Committee on May 21, 2015. As this funding request moved through its review process, the climate energy sub-committee worked with two local environmental non-profits to submit a grant application for a City Economic, Cultural, Tourism and Sustainability grant. The grant review committee awarded the groups $10,000 of the $28,540 that was requested. As proposed, the grant recipients intend to utilize the $10,000 grant award to organize and manage a significant kick-off event and other supporting efforts to garner support for the plan development process. Additionally, the kick-off is intended to provide a forum to collect names of community members that may be interested and qualified to be among the pool of people for the Mayor's consideration for appointment to the ad-hoc committee. Page 1 oi' 3 IW N W CITY OF -ASHLAND CAEP Pro iect Schedule To provide context for the creation of the ad-hoc committee and the proposed kick-off events, the Commission created a draft CAEP planning schedule. The schedule is intentionally aggressive in order to meet the self imposed one year plan development target. Staff is in general agreement with the plan schedule with a few exceptions and will work with the Commission and its sub-committee to address several of the identified modifications, such as: • Role of the grant recipients in the plan development; • Timing and use of data collected by grant recipients as part of the initial kick off steps; • Responsible party for the charge and role of the ad-hoc committee (City Administrator is designated by Ashland Municipal Code); and • Role of the Conservation Commission and sub-committee in plan development (possibly resolved by inclusion on the ad-hoc committee). Coordination of roles and tasks associated with the proposed kick-off events will be critical as this will set the tone for much of the plan development. The grant award contract and the RFP for consultant services will need to be aligned and carefully delineated to ensure maximum value of the kick-off event and a smooth transition between the two separate entities. Ad-Hoc Committee Timeline and Responsibilities The Ad-Hoc Committee will act as the central hub for the plan development and will be made up of community members who have the time, ability and interest in serving the community over a 9 to 12 month period in developing recommendations from a variety of community sources. The oversight committee will be the official sounding board for staff and consultant plan development efforts and will function as the final recommendation body prior to the final draft plan presentation to Council for adoption. Key committee dates include: • Approval of Ad-Hoc Committee formation - June 2, 2015 • Establishment of committee scope of work - July 2015 • Committee member appointments - August 4, 2015 • First Committee meeting - September 2015 • Meeting Schedule - One to two meetings per month • Draft plan presentation to Council - July 2016 Ad-hoc Committee Municipal Code Reference AMC 2.04.090 B. The Mayor shall have the authority, with the consent of the Council, to form ad-hoc committees or task forces to deal with specific tasks within specific time frames. Such ad hoc committees shall abide by uniform rules and procedures set forth in AMC 2.10 and such other rules as prescribed by the order establishing such ad hoc entities. Committees shall make recommendations by way of a formal report to the City Council. The Mayor or City Administrator may refer matters to the appropriate ad hoc committee. The Mayor with the consent of the Council shall appoint the membership of such committees. Members of Regular Boards and Commissions may be appointed to ad hoc committees. The City Administrator shall by order establish the ad hoc body's scope of the work and rules of Pa e2of3 Ln N N ~ Inc Lr) n~ 1 4- ro ~ n N M O M V) ~ Q) Q) Q M1;: tl M E U =3 u Q 4' C _ D e O j m U M m. L U - > (n T u ro c c m LA U U L C 1: 1--I fu J N f: ^ N ~ V C ry N Q) N -f D o-, a U V 0 E Q a (n -0 F- 0 o M ~ -0 L 41 4 x U 4 0 ) _ N 0- o o 4 U Q) UClC uM Ua' V)U - U 00 U c W 0 row row O - c o.u U~44-4~--4-u" ~C7 ~U` C7 > 3U Ur` z zz zzo o o W ' N L r6 f6 ro ra f° U O U O O p O co m U1 ro U U M 4-J 4~ + O U o U U H- p ra U U - + c rYa cncnWU)MMMUMUlm cn C7(DU2: 0(DU(D(DO UODU UUF ~ C7 M I I 0) D E N 4J ro y L 0 e C: 41 O LL LL N (n C rn Q) ro 0 0 ro U `J N _0 Q) 0 Q) 4~ Q) ro L d L L L r6 u a E N O > X C 7 -C p i O N 0 0 0 N U) 0 (n N .4' M E C 1 C 4; W O Lu - o r1 u ~ U c c c 3 Q) m ° a C E .o u row u C Q) ( a flo U o Q) Q U +-1 v o U a>i . u a _o u E ~ o 0 0 c c c> rr w c c v E u w U 41 a O L U v c 0 U 41-1 (n O c~ E Z flo 41 (n c v U~ f s-- a) ~ o Y O u ro c> 4.1 O (n Q) N (n 0 (n CK 0 O 0~ o L 0 OU E a L - C~ O 0~ i ro v 0 u ~ 4.1 c 0 U E C L 0 E r6 f6 (o > a C !Z o L U C '(n 0) u O U 0 F- U-0 a r0 u v a0 Ot ro (D (D 0 LL 0 Q) (d u_ a0.+ 4- O L C L > t0 41 o L 0 w- U -0 C u E O 0 ro r (n M C m 3 N N 0 a tY L 0 L C U N 0 0 0 U) N - ro -O Q) O 4 ~ U C O LL N to c (n a N ~ (a > . L. L > L ..0 U 4~ ro M N U o_ X u c o v~ Q U) c O Q) 5~-j~ c p a r° 4-+ 4) 7 0 0 0> c _ u L C u u 0 E > L L a) 0 c O a u L c w ro a U .0) 1 L o cn 0 v}± ra a v (3) LL v c •L V O (n r(a C C C- LL U 41 > o N E U U_ U_ pl 7 7 3 C N U M L. N _ _ C N O u 0) 4~ _0 v a~i v c O b v a +LLJ ~ ° v c> ro > ra - C U 0 L U N o L L L 2 2 U 53 f0 L L 0> 0 v 0 0 7 v C 0 0 N W 4f OL C o N 0 II Q) 4-J -0 CY ~mUoaU(~C~C7(D C7 co °au 0000cn~aa -LLLuuu Q aE II Ln E E E E E w 0 0_ _ ro .0 u _0 0 ro .0 u "0 a) ro M -0 u _0 4) ro M ro -0 u p Q) ro ro 0) (n 0 N N U 0 N ( ,-I r I i i N N N N N r) It It It ~ It Ln l0 r\ r\ N N n 00 M ro Q Ln aaaaa 0 ~ Ln N N n n ro L Q ~ U O m ~ a O 73 E N O ' E ~ U cn O U V ` O~ n m ~4-1 U m m -zl c II O C7 ~ fu a~ 1 C7 ~ U C Lr) O vv V a o~ Q Q C2 E ° o U N 7 N c ~ W U') LU 0 N - E U u~ a a-J O L Fn ° u u v ° p O O .Z U fu (o o L 4- U 0) C: Z rn O _0 c U II z jj 0 5-22-2015 Draft detailed steps in the proposed Climate and Energy Action Planning (CEAP) process. These steps align with CEAP timeline and Gantt chart. Preliminary a. Bring next steps to Conservation Commission for vote b. City Council agrees on steps c. Develop consultant RFP for planning process - Consultant will gather data frorn public input, local experts and emissions reductions targets. RFP should contain: skills in running interactive workshops/meetings with diverse backgrounds that encourages ownership and transfer of knowledge to all involved. Knowledge of climate change/energy planning. Depending on timing of the hiring of the consultant, the consultant agrees to enter into the process during or after the grantees efforts. The consultant agrees to consult the topic groups that were formed at the kickoff event d. Release RFP e. Contract awarded -Consultant to start work in August 1. Greenhouse Gas Inventory (GHGI) - The City conducts or contracts a greenhouse gas inventory that includes a subset for city operations (transportation is included); this inventory will also benefit the city operational sustainability plan that has already been adopted by City Council. The purpose of the GHGI is to identify local sources of GHG emissions so we can direct resources in the most efficient and cost-effective manner possible. a. GHGI RFP - Specific reporting requirements should be identified in RFP (e.g. seasonal variations, transportation, electricity, scope 3 emissions). b. GHGI Report - The City conducts or contracts a greenhouse gas inventory (GHGI) following GHGI standards. The Oversight group enters into the scene after they are up and running. The GHGI that includes a subset for city operations (transportation is included); this inventory will also benefit the city operational sustainability plan that has already been adopted by City Council. The purpose of the GHGI is to identify local sources of GHG emissions so we can direct resources in the most efficient and cost effective manner possible. c. GHGI Draft - Release draft d. GHGI Review - Small team review e. GHGI Final Report Release 2. Leadership - Appoint a City/Citizen Oversight Group, which will create a Technical Advisory Committee to set scientifically valid GHG emission goals, engage community members, interface with other groups, conduct outreach, guide strategy development, and prioritize actions. City Staff will support the Oversight Group as needed. See Appendix III for more information. a. Identify Ashland CEAP Champions - Seek City Council member(s) and others who agree to be active champions of the Ashland CEAP process. b. Build a list of potential leadership participants for GIRC process - Based on the list of categories in the original CEAP process, we will develop a list of potential kickoff CGIRC) leadership members to ask to serve. This group's role will be to provide recommendations for the Oversight Group membership, get citizen input on GHG emissions targets, and provide guidance and leadership for a successful Kick-off Event. This initial GIRC leadership group will convene through the end of the kick-off event, but the Oversight Group will guide the process during later stages. There may be overlap in membership. c. Create charter, roles, responsibilities for Oversight Committee - Review by SC d. Outreach and collect potential Oversight Committee names - Outreach includes names and interest. GIRC leadership group reviews list e. Appoint Oversight Committee - Appointing may help to keep people involved and on task. There is a risk that it may become bureaucratic. 3. Set Emissions Reduction Targets - Many communities use targets set by state government, while others decide on more stringent targets for their community. The Technical Advisory Committee will investigate and recommend appropriate targets for Ashland. a. Set emissions reductions targets - a team of experts will set emissions reduction targets based on input from the OC and the public from the Kick-off event. We will collect public input through outreach, polling, and kickoff participants. 4. Public Outreach - Hold a public kick-off event that informs community members about the effort, engages them on the issue, collects their input on areas of highest priority, and showcases positive stories and successes in energy savings and renewable energy. a. Identify partner organizations for kickoff event b. Public outreach for event - Aug. for general public. Oct. for SOU students. c. Public Survey on Climate and Energy - SOU assist in the design components: questions, type, etc. The survey should be conducted in a variety of means d. Kick off event - large event as planned by GIRC, OC, and other local partners e. Feedback based on kickoff event outcomes - Communication back to the public on findings. S. Engage Local Experts - Convene sector specialists to develop initial lists of strategies and prioritize them in a collaborative manner, based on cross-sector discussions of synergies, short- vs. long-term goals, areas with the greatest/fastest potential energy savings, most vulnerable resources and populations, and issues of equity and local values. a. Convene sector specialists to develop initial lists of strategies and prioritize them in a collaborative manner, based on cross-sector discussions of synergies, short- vs. long-term goals, areas with the greatest/fastest potential energy savings, most vulnerable resources and populations, andissues of equity and local values. Categories of Expertise: human health, climate, energy, transportation, emergency response, natural resources, water, etc. 6. Consult with City Council and City Staff - Hold a working session with City Council and City Staff to further refine and prioritize emissions reduction strategies and climate change preparedness strategies. City to identify a number of actions for immediate implementation. a. Consult with City Council and City Staff (see above) 7. Finalize the Plan - The plan should include emissions targets, a timeline, high level goals, specific strategies, and actions that are organized by short and long term implementation horizons. The plan should include an implementation plan that specifies who is responsible for specific actions, a monitoring plan to assess progress, and periodic updates to the plan. a. Consultant to draft plan b. Review Draft Plan - Technical Experts, Commission(s) and City Council Study Session(s) c. Feedback and revision - Feedback as appropriate and revisions, as needed d. Attain Public Feedback on Plan - Obtain public feedback via public meetings and other avenues e. Provide feedback from public - as needed to Tech Experts/Commissions/City Council f. Finalize plan 8. Get Feedback/Conduct Outreach - Hold an open forum workshop(s) to share information and collect feedback. Also use online forums, local TV and radio, printed media, and other outreach tools. Report the results online in other venues, as appropriate, with recap of the process, detailed strategies, and timeline. 9. Implement - Implement strategies in phases, following implementation plan. 10. Assess performance - Measure and report on results periodically (every 1-3 years) 11. Reassess - Revise based on new information, ongoing trends, new technologies, and results from monitoring. Develop additional measures to protect the community from climate change impacts. 12. Educate - Continue with public outreach and education for sustained efforts. CITY OF ASHLAND Council Communication March 16, 2015, Study Session Ashland Conservation Commission Community Climate and Energy Action Plan Proposal FROM: Adam Hanks, Management Analyst, Administration - adam@ashland.or.us SUMMARY Based on direction from Council at the September 15, 2014 Study Session, the Conservation Commission began a focused effort to develop a process, goals and resources framework for a community climate and energy action plan. The plan includes high level goals, sectors to be addressed, project scope, timeline, resource requirements and an outline of suggested steps to begin implementation of the plan process. Also included in the plan proposal is a review of climate action planning in other communities within the state and beyond, which were utilized to develop the community plan proposal for Ashland. The Commission is seeking comment and feedback on the plan framework and recommends that the project to be funded in the upcoming biennial budget process (FY2015-17). BACKGROUND AND POLICY IMPLICATIONS: The Conservation Commission has for some time been interested in the City increasing its efforts and focus in the area of sustainability and has spent many years working on both individual sustainability related projects as well as the development and approval of more broad policy level sustainability initiatives to embed sustainability principles into City and community decision making. This current proposal and request is a result of the Commission's request for Council consideration for the 2011-12 Council goal setting process. The following goal was approved as part of the final Council goals for 2011-12, as amended by Council in May of 2012: "Develop a concise sustainability plan for the community and for City operations, beginning with development of a plan framework, suggested plan format, timeline and resource requirements for City Operations that can be used as a model for a community plan to follow " In November of 2012, Council approved the Commission's suggested Operational Sustainability Plan Framework, Plan Format and Process Outline document that staff has subsequently used as the basis for development and implementation of a formal Operational Sustainability Plan. In September of 2014, the Commission presented Council with a proposal to adopt and utilize the STAR Communities framework, a tool developed originally by ICLEI, Sustainablity for Local Governments, then spun off as its own national template for local government sustainability planning, pape I of 3 IWALAR CITY OF ASHLAND implementation and measurement. At that meeting, Council reviewed the broad matrix of topics/issues covered by STAR Communities and, rather than moving forward with the complete set, asked the Commission to instead develop a plan that would address climate and energy action specifically (one of seven major topic categories of STAR). The Conservation Commission re-focused the existing sustainability sub-committee of the Commission and began work on developing a plan to address climate and energy action that would meet the goals and objectives of the Council and the community. The sub-committee met twice a month over the past five months and provided three reports to the full Commission with the end result being the Climate and Energy Action Plan included in this meeting packet. A significant component of their work involved research and review of other community level Climate and Energy plans from different communities within Oregon and beyond. The results of this research can be found in Appendix 11 of the document and include the following summary: overall assessment: MOST plans are: • Based on a long-term positive vision for the community • Sponsored and/or led by City or County government • Based on a conimu pity-wide greenhouse gas assessment • Focused on time horizons of 15-25 years (mostly due to California mandates) • Iterative in nature, with regular monitoring and reassessing to track progress • Both City and Community in scope • Based on greenhouse gas emissions targets set at the state level But SOME communities go further and create more robust plans. MANY plans have: • Goals/strategies specific to near, mid, and long term time horizons • Greenhouse gas savings calculated for each specific action • Cost and/or cost savings calculated for each specific action • Adaptation strategies incorporated in with mitigation strategies for each sector • Strategies developed from highly collaborative community-bused workshops and meetings • Education on climate change as a primary strategy • Social equity goals also addressed • Population and business growth calculated into the emissions savings equation • Goals for carbon neutrality • Acknowledgement of the urgency of the issue • Plans for more adaptation strategies to be developed over tinie Additionally, the sub-committee found the Eugene Climate and Energy Plan especially relevant and has provided a more in depth review of that document as well, which can be found in Appendix V of the action plan. Page 2 of 3 IWA111 CITY OF ASHLAND COUNCIL GOALS SUPPORTED: Energy and Infrastructure 22. Prepare for the impact of climate change on the community 22.1 - Develop and implement a community climate change and energy plan FISCAL IMPLICATIONS: The Commission recommendation includes a funding request for the FY2015-17 biennium based on the equivalent of a .5 FTE project coordinator level position. This funding would allow for the use of contract employment, consultant work or new City staff depending on need as the plan development moves forward. Staff has estimated the equivalent cost of the .5 FTE position at $60,000 per fiscal year for a total proposed resources request of $120,000 for the FY2015-17 biennium. This would be in addition to existing staff participation in the plan development, including general project management, subject matter staff expertise (Public Works, Electric, Conservation, Administration) STAFF RECOMMENDATION AND REQUESTED ACTION: No formal action requested of Council, this item is for discussion, feedback and general direction. SUGGESTED MOTION: N/A ATTACHMENTS: Conservation Commission Community Climate and Energy Action Plan - March 9, 2015 Rogue Climate, Oregon Action - Letters of Support September 15, 2014 Council Study Session Minutes - http://www.ashland.or.us/Agendas.asp?Display=Minutes&AMID=5788 Page 3 of 3 ~r, Conservation Commission Recommendations for a Climate and Energy Action Plan for the Community of Ashland, Oregon March 9, 2015 Background: Climate change poses a severe threat to the health, safety and livelihoods of current and future residents of Ashland, as well as people around the globe. Climate change also severely threatens the natural world and the resources we depend on. We are already feeling the impacts of climate change at the local level. Without emissions reductions, severe drought, floods, and wildfires are all expected to worsen and accelerate over time. Local impacts are already being felt, including a lack of snow and loss of revenue at Mt. Ashland; water restrictions during severe drought, such as those in 2014; and smoke from forest fires affecting the tourist industry when plays are cancelled and rivers are closed for rafting. By reducing emissions locally we can contribute to preventing increasingly severe impacts. Because many changes are inevitable due to gases already emitted, we also need to prepare our community for the changes ahead. The community of Ashland, with its strong history of conservation and a population engaged in the issue, is poised to take truly meaningful action on this extremely important issue. State Level Efforts and Policies: In 2004, the state of Oregon passed a resolution to combat climate change by setting short and long term targets for reducing greenhouse gas emissions statewide. The state has goals to reduce emissions by 10% below 1990 levels by 2020 and 75% below 1990 levels by 2050. A recent report (Oregon Global Warming Commission 2013) shows that progress has been made and our state is on a trajectory to meet its targets, but that success is tenuous and sustained efforts are not yet in place. Success at the state level relies heavily on actions taken at the local level. See Appendices I and II for more information on state and local actions. The vast majority of state universities in Oregon, including SOU, has created Climate Action Plans and has dedicated sustainability staff. Why our community needs to take action: As climate change has progressed unabated and new scientific evidence has become available, the urgency of immediate and forceful action has become increasingly clear. The state will not be able to meet its short and long term goals without action on greenhouse gas (GHG) emissions at the local level. Many communities in Oregon are already taking action to reduce emissions. Because of this, there are numerous plans and frameworks that Ashland can model its efforts after, reducing the investment in planning and moving more quickly to action. Action on climate change provides numerous benefits besides greenhouse gas emissions reductions - it also provides cleaner air and water, locally sourced energy that creates a stronger local economy, and monetary savings for residents that conserve energy. In addition to GHG emissions reductions, the community needs to become more resilient in the face of increasing likelihood of extreme events such as heat waves, drought, severe wildfire and floods. Addressing community vulnerabilities and developing cross-sector strategies are both vital for increased community resilience. Goals of a plan for Ashland: 1. Conduct a highly collaborative cross-sector effort on climate change, driven by a City/Citizen Oversight Group, which in turn is supported by a Technical Advisory Committee and City Staff (Appendix III); and with extensive community input, engagement and ongoing educational outreach. 2. Develop a Climate and Energy Action Plan for the Community of Ashland (including city operations as well as all residents, businesses, schools, and others) that includes greenhouse gas emissions targets, specific goals and strategies, an implementation plan, timelines, and monitoring requirements for reducing GHG emissions throughout the Community of Ashland. 3. Identify risks and vulnerabilities of a changing climate to the community and resources of Ashland; develop, prioritize, and implement strategies to protect the community from climate change impacts. 4. Participate in regional efforts to reduce emissions across jurisdictions, including city and county. Specific sectors to be addressed: • Infrastructure • Renewable Energy & • Land use & Transportation • Economics & Tourism Energy Efficiency • Consumption & Waste • Natural Resources • Food & Agriculture • Health & Social Services 1 Scope: The Community of Ashland, City Operations, the Ashland watershed and other areas of influence. Timeline: Planning to begin in spring of 2015 with implementation of initial actions to begin no later than spring 2016. The plan will continue to be revised over time to include more adaptation strategies and update mitigation strategies, as needed. Resource needs: At least 0.5FTE staff time or equivalent in contracted assistance this FY15-17 to manage the development of the Climate and Energy Plan (year 1) and begin to implement the plan (year 2). Steps in chronological order: 1. Greenhouse Gas Inventory - The City conducts or contracts a greenhouse gas inventory that includes a subset for city operations (transportation is included); this inventory will also benefit the city operational sustainability plan that has already been adopted by City Council. The purpose of the GHG inventory is to identify local sources of GHG emissions so we can direct resources in the most efficient and cost-effective manner possible. 2. Leadership - Appoint a City/Citizen Oversight Group, which will create a Technical Advisory Committee to set scientifically valid GHG emission goals, engage community members, interface with other groups, conduct outreach, guide strategy development, and prioritize actions. City Staff will support the Oversight Group as needed. See Appendix III for more information. 3. Set Emissions Reduction Targets - Many communities use targets set by state government, while others decide on more stringent targets for their community. The Technical Advisory Committee will investigate and recommend appropriate targets for Ashland. 4. Public Outreach - Hold a public kick-off event that informs community members about the effort, engages them on the issue, collects their input on areas of highest priority, and showcases positive stories and successes in energy savings and renewable energy. 5. Engage Local Experts - Convene sector specialists to develop initial lists of strategies and prioritize them in a collaborative manner, based on cross-sector discussions of synergies, short- vs. long-term goals, areas with the greatest/fastest potential energy savings, most vulnerable resources and populations, and issues of equity and local values. 6. Consult with City Council and City Staff - Hold a working session with City Council and City Staff to further refine and prioritize emissions reduction strategies and climate change preparedness strategies. City to identify a number of actions for immediate implementation. 7. Finalize the Plan - The plan should include emissions targets, a timeline, high level goals, specific strategies, and actions that are organized by short and long term implementation horizons. The plan should include an implementation plan that specifies who is responsible for specific actions, a monitoring plan to assess progress, and periodic updates to the plan. 8. Get Feedback - Hold an open forum workshop(s) to share information and collect feedback. Also use online forums, local TV and radio, printed media, and other outreach tools. Report the results online in other venues, as appropriate, with recap of the process, detailed strategies, and timeline. 9. Implement - Implement strategies in phases, following implementation plan. 10. Assess performance - Measure and report on results periodically (every 1-3 years) 11. Reassess - Revise based on new information, ongoing trends, new technologies, and results from monitoring. Develop additional measures to protect the community from climate change impacts. 12. Educate - Continue with public outreach and education for sustained efforts. 2 Appendix I - Roadmap 2020 In 2010, the Oregon Global Warming Commission developed the Roadmap 2020 with recommendations on how to meet its 2020 greenhouse gas emissions goals and get a head start on its 2050 goals. Six technical committees were convened to address actions in specific sectors (energy/utilities, industry, forestry, agriculture, materials/waste management, and transportation/land use). Recommended actions came from each technical committee as well as additional "integrating" actions that work across sectors. Some key actions included: • Work with state agencies and local governments to conduct greenhouse gas inventories across the state • Advocate for a carbon price signal across goods and services, through an emissions cap or a carbon tax • Reduce (prevent) waste of food at the retail and consumer level by 5-50% • Ramp down emissions associated with coal generation • Provide financial incentives to reduce lifecycle building-related greenhouse gas emissions by 80% • Eliminate reliance on a gas tax for funding transportation infrastructure • Develop new funding streams to support climate-friendly transportation options, including high speed rail from Eugene to British Columbia • Encourage agricultural practices that increase carbon sequestration in soils • Prepare the agricultural industry for reclining reliability of water resources For more information on the Roadmap 2020 and the full report go to this link (http://www.keeporegoncool.org/content/roadmap-2020). For the third biennial report (2013) to Legislature from the Oregon Global Warming Commission go to this link (http://www.keeporegoncool.org/view/ogwc-reports). 3 Appendix II - Review of Climate Action Planning in other Communities The Climate and Energy Subcommittee of the Conservation Commission reviewed numerous Climate and Energy Action Plans from other communities. We found certain aspects of the different plans to be informative in our efforts to develop strategies for Ashland. We have listed plans that we think are good examples in Table 1, along with some of their more outstanding or unique features (shown in bold in Table 1). Definitions • Mitigation refers to reduction in greenhouse gas concentrations in the atmosphere in order to reduce the overall magnitude of climate change. Effective mitigation requires concomitant emissions reductions throughout the U.S. and other key nations, as well as increased carbon uptake in forests. Mitigation is needed to protect people from the most severe impacts over the long term. • Adaptation refers to actions taken to protect people and resources from the impacts of climate change. As climate change is already being felt and impacts will worsen for decades based on emissions already released, adaptation is needed along with mitigation. Overall assessment: MOST plans are: • Based on a long-term positive vision for the community • Sponsored and/or led by City or County government • Based on a community-wide greenhouse gas assessment • Focused on time horizons of 15-25 years (mostly due to California mandates) • Iterative in nature, with regular monitoring and reassessing to track progress • Both City and Community in scope • Based on greenhouse gas emissions targets set at the state level But SOME communities go further and create more robust plans. MANY plans have: • Goals/strategies specific to near, mid, and long term time horizons • Greenhouse gas savings calculated for each specific action • Cost and/or cost savings calculated for each specific action • Adaptation strategies incorporated in with mitigation strategies for each sector • Strategies developed from highly collaborative community-based workshops and meetings • Education on climate change as a primary strategy • Social equity goals also addressed • Population and business growth calculated into the emissions savings equation • Goals for carbon neutrality • Acknowledgement of the urgency of the issue • Plans for more adaptation strategies to be developed over time 4 Table 1. City/Community Climate and Energy Plans reviewed for this effort. AuSL111, TX ,A 2014 City Mitigation Y sin2010 11i1,11:arbon neutral by 2020 Net Zero communi wide b 2050 Details: Austin City Council adopted a resolution in 2007 and another one in 2014. Their 2014 resolution states that they will develop acommunity wide climate action plan, with the following topics to be addressed: targets (the resolution specified the targets, as listed above), specific sectors and populations to assess (energy use, transportation, landfills, manufacturing, with community growth factored in), community input and advisory groups, accountability, barriers to progress, monitoring and updates, and responsible entity (City Manager). Chico, CA 100,000 2010 City, CSU Mitigation Yes 5% below 2005 by 2015 (includes Chico, 20% below 2005 by 2020 rural Community areas members Details: Chico developed a Climate Action Plan to reduce emissions across the Energy, Transportation, and Waste sectors. Their plan provided specific emissions targets for each sector and also provided a breakdown for City vs. Community emissions. The Chico plan provides detailed steps for how they created their plan and could be a useful guide for Ashland. Their plan also includes a cost-benefit analysis. Tbey are developing an Adaptation Plan. Some notable actions include: (1) expand landfill methane capture; (2) consider carbon emissions in contracting for city projects; (3) pursue installation of purchase power- agreements on city property; (4) weatherization program for low income homes; (5) develop an urban forest plan. Corvallis, 55,000 2014 Task Force Both Yes in 2012 10% Mow 1990 by 2020 OR draft (volunteer) T75% below 1990 by 2050 Reduce fossil fuel use 50% b 2030 Details: Corvallis' plan is tieing created by a volunteer Task Force working with the Urban Services Committee (City). They held 2 public forums to collect input. Their plan is created with !a sense of urgency, focused on City Council and Staff, and through a lens of social equity. Some notable actions include: (1) support the Georgetown Energy Prize effort; (2) re-write building codes to follow Architecture 2030 or another maximum efficiency standard; (3) transition to 100% renewable by 2030 by supporting renewable energy projects and carbon tax efforts; (4) establish car-free streets downtown. Eugene' OR 160,000 2009 City, Both Yes in 2007 City Ops carbon neutral by 2020 Springfield, - 10% below 1990 by 2020 other C;ommunitywide partners Fossil fuel 50% below 1990 b 2030 Details: Eugene City Council asked City Staff to develop a Climate Action Plan. They worked with many partners, from universities to NGOs and private citizens to develop a`joint mitigation and adaptation plan for the whole community. The sectors they looked at included Buildings and energy, Food and agriculture, Land use and transportation, Consumption and waste, Health and natural resources, and Urban natural resources. Some notable actions include: (1) target multi-family housing for energy efficiency upgrades; (2) public institutions purchase climate friendly goods and services; (3) create 2-minute neighborhoods for basic needs and services in walking distance; (4) support electric charging stations in multi-family housing; (5) conduct a Vulnerabilit Assessment for health and Human Services impacts from climate change. Fort 152,000 2005 City Mitigation Yes ' 20% below 2005 by 2020 Collins, CO 80`Yo below 2005 by 2050 Details: Fort Collins created a Climate Action Plan that works across the community with both mandates and voluntary measures and a significant public outreach campaign. They are currently working on 5 Adaptation strategies to complement their mitigation strategies. They showed the cost savings of the measures in their plan. Some notable actions include:, (1) increase tree canopy to reduce energy demand; (2) outreach to business community; (3) require green building to get public financing; (4) aim for 500/1 waste diversion; 5 promote Net Zero read homes. Grand 188,000 2013 City and Both Yes in 2009 7% reduction in emissions by 2012; TCLE[ Continue to reduce emissions l% per Rapids, MI year Details: Grand Rapids was awarded the Climate Protection Award by the U.S.Conference of Mayors. They completed a "Climate Resiliency" Report that outlines cross-sector strategies for preparing for climate change impacts and reducing their emissions. They addressed economics (energy, infrastructure, transportation, agriculture, risk management), environmental issues (water, land use, wetlands, forests, parks), and social impacts (emergency response, health, crime). Some notable actions include: (1) increase tree canopy by 40% to reduce energy use; (2) use porous pavement as flood abatement; (3) power 100% of city operations with renewable power by 2020; (4) Protect underserved, minority, and low income populations from the disproportionate climate change impacts; (5) Restore rivers to more natural state to imp hove water quality and enhance flood protection. Missoula, 69,000 201 City Both Yes in 2008 10% below 2008 by 2015 MT Operations 50% below 2008 by 2020 carbon neutral by 2025 Details: The City of Missoula, Montana committed to become climate neutral by 2025. Their Conservation and Climate Action Plan focuses on conservation and energy reduction measures, along with carbon offsets. They plan to track costs, energy/monetary savings, and avoided emissions over time, specific to each implemented strategy. Their plan focuses on city operations. They used the Climate and Air Pollution Planning Assistant (CAPPA) online tool available through ICLEI, to calculate energy savings, avoided emissions, and dollar savings. Some notable actions include: (1) need for immediate action; (2) they dedicated a FULL TIME staff position to implementing the plan; (3) replace city vehicles with electric/hybrid vehicles over time; (4) recommission city buildings to reduce energy use 16%; (5) incentives for ridesharing and flexible work schedules; (6) include sustainability measures in all job descriptions and performance reviews; (7) increase PV systems on ci buildings from 2 buildin s to'23; 8 expand Conservation Lands Program. Oberlin, OH 8,400 2011 City Mitigation Yes in 2007 50% below 2007 by 2015 70% below 2007 by 2030 100% below 2007 b 2050 Details: Oberlin College committed to become climate neutral by 2025. The city joined the pledge in 2011 with their Climate Action Plan that focuses on renewable energy, energy efficiency, transportation, green building, waste management and education. Some notable actions include: (1) increased efficiencies in heating, cooling, and lighting; (2) embrace the Architecture 2030 Challenge; (3) reduce solid waste 2%peryear; (4) create community and business environmental awards; (5 hold community workshops. San Luis 46,000 2012 City, Cal Both Yes in 2008; 15% reduction from 2005 baseline by Obispo, ~A Poly, City/Community 2020 Contractor Details: The city provides specific greenhouse gas emissions, goals for each sector (Buildings, Renewable energy, Transportation and Land Use, Waste, Government Operations, and State Policies) and details the carbons saved with EACH strategy. A table on pages 59-62 shows the GHG savings for each strategy, timescale for each, cost, and the responsible entity. Some notable actions include: (1) expand energy efficiency retrofits; (2) work with the County to develop network for renewable energy financing; (3) mandate electric vehicle charging stations; (4) install renewable energy systems on City buildings; 5 allocate hire staff to implement CAP programs. 6 Fig. 1. Example from Missoula, Montana's Climate Action Plan. Comparative energy and cost savings/monetary costs for each proposed strategy. Figure 3-1: Comparison of Conservation and Climate Action Strategies h .jraphl • Water Wise Park Areas Paper and Printing Policies Water Wise Bathroom Features Shut Off/Remove Water Fountain Cooling Efficient Fleet Vehicle Purchasing (Fuel economy) $400 m~v vU $300 f ° Eco Drivers Manual Continuous Building Retro and Re-commissioning for Existing Buildings Bike Fleet Infrastructure Hybrid/Electric Vehicle Purchasing Q Expand Route Optimization Software/GPS $200 Reduce Electronics Energy Use LEED for New Construction and Major Renovations Policy LEED Existing Buildings: Operations & Maintenance Policy 78 m $100 Micro-hydropower Electricity Generation at WWTP o Real-time Energy Monitoring Systems c f o Urban Tree Planting and Maintenance o $0 Rideshare Scheduling plan for employees' Flexible Work Scheduling -$100 Employee Commuting Incentive Program i Enhance Methane Utilization at WWTP 0 v -$200 - Solar Thermal Heating System and Thermal Pool Blanket at Splash ° Montana and Similar Energy Efficiency Improvements at Currents w Poplar Plantation near Wastewater Treatment Plant rn > -$300 cn Solar PV Installations on Municipal Buildings Missoula Open Space Portfolio -$400 Groundwater Cooling Systems (o" Visual Comparison of Strategies This graph is a visual comparison of strategies based on annual emissions reduction and cost. The benefit of having this graph is the ability to quickly compare strategies to see which have larger emissions reductions and best cost benefits. The width of each bar is relative to the amount of emissions reduced annually. The wider the bar, the more emissions are avoided every year. The height of each bar above or below the horizontal axis is relative to the savings (positive) or cost (negative) per metric ton of emissions avoided. The savings/cost value is a way to take three important metrics from each strategy (implementation cost, annual savings, and annual emissions reduction) and combine them into one value that can be used to compare all of the strategies at once. Bars extending above the axis generate a net savings. Bars extending below the axis generate a net cost. The strategies are listed in order of greatest savings pelt) to greatest cost (right). CONSERVATION AND CLIMATE ACTION STRATEGIES CITY OF MISSOULA CONSERVATION & CLIMATE ACTION PLAN 19 Appendix III - Oversight Group, Advisory Committee and City Staff Recommendation - City/Citizen Oversight Group and Technical Advisory Committee to be comprised of a mix of people from many the following areas. The Oversight Group will create a Technical Advisory Committee to help set scientifically valid GHG emission goals, engage community members, interface with other groups, conduct outreach, guide strategy development, and prioritize actions. City Staff will provide support to the Oversight Group, as needed. • Ashland School District • Rogue Climate and/or SOCAN • Chamber of Commerce • RVTD • Transportation and Planning • Clean Energy Works Commissions • City Councilors • Conservation Commissioners from • City building/engineering experts the Climate/Energy Subcommittee • OCF, other community foundations • Watershed oversight • Tourism sector (e.g. OSF, hotel • Jackson County Housing Authority facilities experts) and/or ACCESS • Recology Ashland Sanitary Service • Utilities • Community at large • SOU Appendix IV - Some initial actions that other cities are taking and that Ashland could consider implementing quickly • Virtual net metering - allows for renewable energy to be generated on a separate site but owned by people with other accounts and in other areas. Allows cooperatives and other investment sharing opportunities (Eugene) • Expanded education and outreach on climate change impacts, preparedness, renewable energy opportunities, and energy conservation (San Luis Obispo) • Evaluate incentives for highly energy efficient buildings aiming for net-zero construction and retrofits (Eugene and Corvallis) • Energy performance score program for new residential construction - voluntary • Explore possibilities for utility scale solar • Assess viability of Bonneville hydroelectric generation with climate change • Conduct a pilot project at waste water treatment plant to determine the system ability to co-digest food waste and bio-solids to generate electricity (Eugene) • Develop and implement master pedestrian and bike plan (Eugene) • Ultimate goal for becoming platinum level bike - friendly city • Diversify funding sources to increase long term reliability and affordability of rnass transit (Eugene) • Conduct a climate and energy vulnerability assessment that assesses the mid-term and longer-term climate and energy vulnerabilities of essential services - water, food, health, housing, and sanitation. • Install renewable energy systems on city buildings (Grand Rapids, Oberlin, San Luis Obispo, Missoula, etc.) and/or school district buildings • Strategically increase tree canopy cover to reduce cooling costs over time, especially near schools and other public buildings without air conditioning (Fort Collins, Missoula) • Work with Jackson County to develop a network of renewable energy financing and joint projects (San Luis Obispo) • Support mitigation and adaptation measures at the state level (San Luis Obispo, etc.) 8 Appendix V - OUTLINE OF CLIMATE AND ENERGY PLAN FOR EUGENE, OREGON Population - 160,000 Plan developed - Winter 2008/2009 City Council asked staff to develop plan Plan Development - Assembled in May 2009. 11 team members. t City of Springfield UO Climate Leadership Initiative Eugene Area Chamber of Commerce Eugene Water and Electric Board - Friends of Eugene tr r.° Eugene Human Rights Commission Lane Transit District Lane County Neighborhood Leaders Council City of Eugene Planning Commission City of Eugene Sustainability Commission Goals: 1. All city operations and City-owned facilities were to be carbon-neutral by 2020. 2. Reduce community-wide greenhouse gas emissions 10 percent below 1990 levels by 2020. 3. Reduce community-wide fossil fuel use SO percent by 2030. 4. Identify strategies that will help the community adapt to a changing climate and increasing fossil fuel prices. Action Areas: 1. Buildings and Energy 2. Food and Agriculture 3. Land Use and Transportation 4. Consumption and Waste S. Health and Social Services 6. Urban Natural Resources Public Engagement Process: 1. Kickoff event September 2009 2. One public forum held on each of the six identified action areas between Oct 2009 and March 2010. a. 8-12 topic specialists were identified in each of the six topic areas. b. Strategy list was compiled using information submitted by regional experts and gleaned from municipal and state level climate and energy plans from 9 across the nation. The list was reviewed and refined by the topic specialists and used as a starting place for the public forums. c. Public forums in each of the topic areas. i. Attended by topic specialists ii. Neighborhood leaders iii. Sustainability Commissioners iv. 50-120 community members. d. Topic specialists reviewed proposed actions and strategies that emerged from public forums, provided input on priorities, clarified ideas, identified opportunities and challenges, and helped to ground the process in Eugene's unique economic, social, and environmental conditions. e. Advisory team members weighed information form background documents, input for the public forums, and topic specialist meetings. Team completes a final review of strategies and comments on the draft Community Climate and Energy Action Plan. f. Additional research was conducted after the draft was released to clarify some of the relative costs and benefits of actions. Targets and measures were also added. 3. Final plan only includes action items expected to reduce fossil fuel consumption and Greenhouse Gas Emissions, and to prepare Eugene for the impacts of energy price volatility and climate uncertainty. 4. Funding - In 2011 $200,000 of one-time funding was earmarked for use in implementing the Community Climate and Energy Action Plan. Unique Factors in the Eugene Plan - 1. Internal Climate Action Plan. City of Eugene operations will be climate neutral by 2020. Strategies include: a. Increase energy efficiency b. Increase waste prevention c. Improve purchasing methods d. Offset energy use by purchasing quality carbon offsets. 2. Waste reduction plan - Reduce waste 90% by 2030. 3. Food Scope Document. Worked towards improving food security in Eugene. 4. Inventory of Community Greenhouse Gas Emissions Report done in 2007 Objectives and Actions for Buildings and Energy 1. Reduce total GHG emissions from existing buildings by 50% by 2030. 2. Reduce total GHG emissions from new construction by 50% by 2030. 3. Expand Development of Renewable and District Energy Systems 4. Increase the implementation of climate change preparation strategies for the built environment (adaptation) Objectives and Actions for Food and Agriculture 1. Reduce consumption of carbon-intensive foods 2. Reduce GHG emissions associated with agriculture and food waste 10 3. Increase food security by preserving the productive capacity of the local and regional foodsheds. 4. Prepare food systems for the uncertainties created by climate change and rising energy prices. 5. Increase availability of home-grown and locally-sources food in Eugene Objectives and Actions for Land Use and Transportation 1. Create 20-minute neighborhoods, where 90 percent of Eugene residents can safely walk or bicycle to meet most basic, daily, non-work needs, and have safe pedestrian and bicycle routes that connect to mass transit. 2. Increase density around the urban core and along high-capacity transit corridors 3. Include the potential for climate refugees when conducting land use planning. 4. Continue to expand and improve Eugene's bicycle and pedestrian infrastructure and connectivity to increase the percentage of trips made by bike and on foot. 5. Increase the supply of integrated, convenient, efficient, and cost- effective public transit 6. Expand outreach, marketing and education about climate-friendly transportation alternatives 7. Ensure maximum efficiency in current and future freight systems 8. Increase the use of low-carbon vehicles and fuels to improve overall fuel-efficiency and reduce vulnerability to fluctuating oil prices. Objectives and Actions for Consumption and Waste 1. Reduce greenhouse gas emissions by addressing purchasing habits 2. Increase waste diversion by improving recycling 3. Increase waste diversion rate for organic wastes 4. Conduct research to determine the most effective next steps in the area of consumption and waste 5. Reduce greenhouse gases in municipal operations by changing purchasing practices and reducing waste Objectives and Actions for Health and Social Services 1. Prepare community systems for longer-term climate and energy challenges including fuel shortages, increased summer drought and increased storm intensity 2. Reduce exposure of human populations to climate-related disasters 3. Increase the capacity of Eugene's health sector, and the community at large, to meet the health-related challenges of climate change and rising fuel prices by fostering greater involvement of the public health system in climate change and energy planning Objectives and Actions for Urban Natural Resources 1. Protect sensitive urban natural areas including riparian areas, wetlands, and floodplains, for multiple benefits including improved water and air quality, reduced water and air temperatures, and reduced flooding 2. Manage and update urban natural resource information, and make data available to public and policy-makers 11 3. Update vegetation management plans. 4. Educate community members about the importance of urban natural resources S. Manage stormwater to reduce flooding, recharge groundwater, and improve water quality 6. Expand public and private programs to manage, and invest in, trees to cool buildings, pavement, and waterways 7. Encourage ongoing water conservation 8. Strengthen protections of drinking water sources. Following are select introductory pages from Eugene's plan. The full plan is available at https://www.eugene-or.gov/Archive/ViewFile/Item/80 12 + ~r FT T. F ff r p It, y k t ` ' ' 1 1 t i 1" ,G r~ rs r r, - CLIMATE&ENF F1MY ugP September 2010 action PL411 fKffCHtiV8 Summary The decade from 2000 to 2009 was the warmest ever recorded.'] Over the last three decades, each has been warmer than the one before and science is telling us that this trend will continue.121 In addition, the inexpensive fossil fuels that our community and country depend on for transportation, food production, and industry are projected to become increasingly expensive.['] Eugene is joining a growing list of cities around the world that are addressing these climate change and energy concerns with a plan to meet the challenges with vision and creativity. In developing this local plan, community leaders and citizens have clearly recognized the need to re4nagine how we live, eat, travel, and play. As we work to adapt to the uncertainties ahead, we can be sure that the boldness of our actions today will determine the quality of life in Eugene now and into the future. Eugene's first Climate and Energy Action Plan: In 2008, in response to increasing concern about global climate change and the potential for volatile and rising fuel prices, Eugene's City Council asked staff to develop Eugene's first Community Climate and Energy m Action Plan. X fp n The Community Climate and Energy Action Plan goals: 1. Reduce community-wide greenhouse gas emissions 10 percent m below 1990 levels by 2020. c 2. Reduce community-wide fossil fuel use 50 percent by 2030. 3 CU 3. Identify strategies that will help the community adapt to a 1 changing climate and increasing fossil fuel prices. The Six Action Areas: Buildings and Energy looks at energy used in residential, commercial, and industrial buildings in Eugene. This section includes recommendations to reduce energy use in existing buildings and new construction, expand use of renewable energy, and prepare buildings for climate change. Food and Agriculture includes everything related to our food production, delivery, distribution, and waste disposal. This section includes recommendations to reduce consumption of meat and dairy foods, reduce greenhouse gas emissions associated with agriculture and food waste, protect regional farmland, increase home- and locally-grown foods, and prepare our food systems for an uncertain future. "State of the Climate Global Analysis, " National Oceanic and Atmospheric Administration, June 2010. 1 "IPCC Fourth Assessment Report: Climate Change 2007, " Intergovernmental Panel on Climate Change, 2007. 3 "Peaking of World Oil Production Recent Forecasts," US Department of Energy, 2007. 3 Land Use and Transportation considers the use of land and the transportation of people and goods. This section includes recomrendations to increase urban density and mixes of land use and a focus on improving systems for bike, pedestrian, transit, and electric vehicles. Consumption and Waste looks at everything in the lifecycle of consumer goods from extraction of raw materials to manufacturing, packaging, distribution, product use and finally, disposal. This section includes recommendations to reduce greenhouse gas emissions associated with consumption of goods, improve recycling and composting, improve municipal purchasing practices, and adapt consumption strategies based on new findings. Health and Social Services addresses mental and physical health care and assistance programs for disadvantaged populations. This section i contains recommendations to prepare health and social systems for a different future and reduce the impacts of climate-related disasters. E, Urban Natural Resources considers the soil, air, water, plants, and animals of our city. This section contains recommendations to manage land, trees, and water for multiple benefits, update resource management plans, improve access to natural resource data, and expand v drinking water and stormwater management programs. X w 4 from the Na Dr The City of Eugene has a long history of environmental stewardship. It is a j' legacy to be proud of. Our planet faces both finite resources and climate change, and the Eugene City Council has committed to an entire new 1 level of local action. The impacts of climate change and increased energy costs affect all of us, regardless of politics, background, or socioeconomic status. These are not simply environmental issues. They are health, economic, social equity and environmental issues. We have learned that climate change is affected by carbon emissions, and that carbon footprints are linked to the food and goods we purchase. All Mayor Kitty Piercy of us need to rethink our consumption of goods, we consume too much and at an unsustainable rate. Our city is part of a broader community, we are part of a world that requires each of us to make significant changes in our lives as governments, businesses, and social service agencies and as individuals - we must all work together more effectively to meet these challenges and T to mitigate negative impacts. o 3 "These are not simply environmental issues. They are health, economic, social equity and environmental issues." c Four years ago we began this journey with the Sustainable Business Initiative to foster our city's leadership in sustainable practices, the triple bottom line of environmental stewardship, economic success and social equity. The Sustainability Commission was formed. Innovative policies and practices moved forward throughout the city, but none more ambitious than the Climate and Energy Plan. The steps outlined in this plan will not only help us reduce our contribution to climate change and improve community resilience, they will also save taxpayer dollars through improved energy efficiency and less expensive transportation options. They will help build the local economy, provide jobs, improve air quality and public health, and community livability. This plan is a true collaborative endeavor and the result of many hours of hard work. I am very appreciative of the remarkable efforts of everyone involved in its creation. Thank you all for this investment in our community. We join over 100 cities in developing emissions reduction targets and creating climate action plans, Together we are a powerful force. Each city, small and large must do its part. Eugene, though modest in size is large in its commitment to the future. We move forward with optimism and a commitment to do our part to ensure a quality future for our city, our country, and our planet. l~ C September 2010 5 Il F. t _ a d r Eu-aene Sustain- Eocene rit Coun, 11 Lie Business y f A' Initiative recom i,Ktructs staff to create a mends creation of community Climate and t Q7 N 1) sustainability Energy Action Plan N commission and 2) • City of Eugene creates metropolitan the first Internal (city climate action operations) Climate plan fiction Plan O • Eugene Mayor signs the • E gene sustainabil City of'Euger,: US conference of Mayors it, ommi-ion is works with "US mayor's climate e,tj I ;hc community piotection agreement partners to h tnving locally to meet or • create Q he,+t the Kyoto protocol Eugene's first M targets Community d Q ~C • City of Eugene creates a . • _ • _ Climate and w Energy Action r U , -4reenhouse gas inventory • - for internal municipal Plan operations 4 it • • a - • i. _ IT. T 9~ w 6 Intruductinn PREPARING FOR CHANGE In the winter of 2008/2009, Eugene's City Council unanimously directed staff to develop a Community Climate and Energy Action Plan (CEAP).~4 All City operations and City-owned facilities were to be carbon-neutral by 2020. During the same year, the Council committed the City to work with its partners to develop a plan to set carbon emission goals, to suggest effective emission reduction strategies, and to identify ways in which the community can adapt to the anticipated changes. Four months later, the Council expanded the action plan to include steps for achieving a 50 percent reduction in community-wide fossil fuel consumption by 2030. This plan is the product of those efforts to understand what climate change and fuel cost increases could mean for Eugene, and to find ways that lessen the expected impacts and meet the goals for reducing emissions and fossil fuel consumption. While there is considerable discussion and some debate on the issues of climate change in the community and beyond, this plan was undertaken in response to Council direction and is informed by the scientific evidence h available at the time of its publishing. 0 c THE COMMUNITY CLIMATE AND ENERGY ACTION PLAN (CEAP) o' Goals 1. Reduce community-wide greenhouse gas emissions to 10 percent less than 1990 levels by 2020 and 75 percent below 1990 levels by 2050.151 2. Reduce community-wide fossil fuel use 50 percent by 2030.11 3. Identify strategies that will help the community adapt to a changing climate and increasing fossil fuel prices. [r Geographic Scope and Timeline Citizens, topic experts and partners from inside and outside of the City of Eugene were invited to develop a plan for the broader community. This public engagement process identified challenges and opportunities and presented options and action items that will require partnerships and 1 More policy detail and background can be joint efforts across the community. found in Appendix 9. Ili' This goal matches Oregon's stated GHG reduc- The CEAP establishes general directions and offers specific actions tion targets from House Bill 3543. While this target is not equivalent to the fossil fuel reduction over the next three to five years; however, the scientific and general target, it reflects the degree of GHG reductions community's understanding of climate and energy challenges are evolving that are necessary, according to scientific research, rapidly and Eugene's direction and goals will like) need to be updated. Additional discussion of relative greenhouse gas likely targets begins on page 14 of Appendix 8. 11' This goal, unanimously adopted by Eugene City Council February 2009, will use the base year 2005, the year of data used for the 2007 com- munity greenhouse gas inventory. The full text of the City Council directives re- lated to the CEAP can be found in Appendix 9. 7 HOW WAS THE PLAN DEVELOPED? The Climate and Energy Action Plan Advisory Team The CEAP advisory team was assembled in May 2009 and was composed of 11 community members and representatives of partner agencies. In June 2009, the team began providing input on the public outreach and general planning processes. The group brought expertise to the public meetings, observed and participated in topic discussions, provided feedback on the development of the plan and the plan document, and provided background data. Team Member Partner Agency/Group Chuck Gottfried City of Springfield Sarah Mazze Resource Innovation Group and The UO Climate Leadership Initiative c Joshua Proudfoot Eugene Area Chamber of Commerce 0 Jason Heuser Eugene Water and Electric Board -a David Hinkley Friends of Eugene Lorraine Kerwood/Fwila Souers Eugene Human Rights Commission 2 C Joe McCormack Lane Transit District Mike McKenzie-Bahr Lane County Jan Wostmann Neighborhood Leaders Council Heidi Beierle/Bill Randall City of Eugene Planning Commission Shawn Boles City of Eugene Sustainability Commission The Public Engagement Process News releases, print and online calendars, website announcements, and emails invited members of the public to participate in seven public forums. A kickoff event was held in September 2009 and one public forum was held on each of the six topics between October 2009 and March 2010. More than 500 members of the public participated, sharing concerns about climate uncertainty and fuel price volatility, and weighing in on what should be the community's highest priorities. Below are the six topics or action areas: ib- Buildings and Energy Food and Agriculture Land Use and Transportation Consumption and Waste Health and Social Services it, Urban Natural Resources 8 The process for identifying action items for each of the six topic areas was as follows: 1. A strategy list was compiled using information submitted by regional experts and gleaned from municipal- and state-level climate and energy plans from across the nation. The list was reviewed by the topic specialists, refined, and then used as a starting place for the public forums. 2. Topic specialists were identified from across the community. Eight to twelve expert community members with broad knowledge of the topic and the ability to bring a variety of perspectives to the public forums were invited to assist with the plan. The topic specialists contributed to the development of the strategy lists, provided technical information support at the public forums, and assisted with the prioritization of strategies. A complete list of Topic Specialists can be found in Appendix 3. 3. Public forums were held to engage members of the community who are interested in climate and energy challenges as they relate to each of the six topics. Each of the forums were attended by 50 to 120 community members, including topic specialists, CEAP advisory team members, neighborhood leaders, and Sustainability o Commissioners. Forum participants reviewed the strategy list CI for the subject topic, provided perspectives on which actions r_ should be given the highest priority, identified missing actions or c• strategies, and provided detail on how individual actions could be implemented. 4. Topic specialists reviewed proposed actions in greater detail, provided input on priorities, clarified ideas, identified opportunities and challenges, and helped to ground the process in Eugene's unique economic, social, and environmental conditions. 5. Advisory team members weighed information from background documents, input from the public forums and the topic specialist meetings, and offered their varied perspectives on each topic area. The team completed a final review of the strategies and reviewed and commented on the draft Community Climate and Energy Action Plan. 6. Additional Research was conducted after the draft was released to clarify some of the relative costs and benefits of actions. This adds confidence that the priorities included in the plan are the best places for our community to take action. Targets and measures were also added.," This information is compiled in the attached spreadsheet, Appendix 1. THE OUTCOMES Of the several hundred possible action items suggested, reviewed, and discussed in the public engagement process, the plan only includes those that are expected to best reduce fossil fuel consumption and GHG emissions, and to prepare Eugene for the impacts of energy price !,The targets associated with objectives and actions in the Plan reflect best estimates of the re- volatility and climate uncertainty. A strict cost-benefit analysis wasn't ductions necessary. Creating targets that are care- feasible, but the project team designed a process that weighs the relative fully calibrated to the overall GHG and fossil fuel importance of potential actions in the context of the three stated goals. reduction goals will require additional research. 9 WHAT HAPPENS NEXT? Funding: In the 2011 fiscal year budget, $200,000 of one-time funding was earmarked for use in implementing both the Community Climate and Energy Action Plan and the City's Diversity and Equity Strategic Plan. These funds are in addition to the work already underway across the City organization in Solid Waste management, the Green Building program, Stormwater Management, Urban Forestry, and many other existing City programs. Reporting back: The City Council will receive annual reports assessing the progress being made on each of the multiple objectives included in the plan. Updating the plan: Our understanding of the complex issues around climate change and greenhouse gas sources is continually improving, and as our community moves forward on the priorities included in this plan, C it will be important to revisit, revise, and update Eugene's Community a Climate and Energy Action Plan every three to five years. HOW IS THE COMMUNITY CLIMATE AND ENERGY ACTION O PLAN ORGANIZED? The strategies are divided into six action areas. The first four are the primary targets for greenhouse gas emissions and fossil fuel reductions, and the last two focus on actions necessary to adapt to climate change and rising fuel prices. Buildings and Energy Food and Agriculture Land Use and Transportation Consumption and Waste Health and Social Services Urban Natural Resources Please note that the actions in each area are not organized by priority. The first action in each section is not necessarily the most important, nor is the last the least important. A table containing all of the actions and associated targets, measures, estimated financial impacts, and estimated greenhouse gas reductions data is available in the Compiled Priority Action Items Tables in Appendix 1. Terms in italics are defined in the glossary located in Appendix 2. 10 City of Ashland City Council 20 East Main St. PO Box 1980 Ashland, Oregon 97520 Phoenix, Oregon March 51h, 2015 97535 Re: Climate and Energy Action Plan (541)-840-1065 Dear City of Ashland City Council, It is with great pleasure that we extend the support of Rogue Climate Inforoueclimate.or to the Conservation Commission and the City Council to develop a Clean Energy and Climate Action plan for the City of Ashland. Cities and counties across the country are taking the lead in stepping up to the challenge of climate change and transitioning to cleaner energy. Due to Ashland's municipally owned utility, Ashland's strong history of leading the state in terms of energy efficiency, and the local impacts we are already feeling in regards to climate change, we are in a great position to take the next step by developing a Community Energy and Climate Action Plan. We look forward to supporting Ashland in these efforts, and believe that any efforts taken in Ashland will have a positive impact in demonstrating to other communities in the Rogue Valley what is possible. We will support this effort by using our network to educate local citizens about the initiative. We will promote participation to our members both through email and at meetings. We can help with publicity efforts by writing about it on our website and facebook page. We can provide a volunteer or staff member to sit on the advisory council and we will continue to work with the conservation commission to find other appropriate roles for our group as they arise. Sincerely, Hannah Sohl Director, Rogue Climate Oregon 33 N Central Ave Medford, Oregon 97501 Action (541)-772-4029 alex aoregonaction.org City of Ashland City Council 20 East Main St. Ashland, Oregon 97520 March 9th, 2015 Re: Climate and Energy Action Plan Dear City of Ashland City Council, Oregon Action would like to express our support to the Ashland City Council and the Conservation Commission for your desire and efforts to develop a Clean Energy and Climate Action plan for the City of Ashland. As a grassroots, member-led organization dedicated to advancing economic, racial, health, and social equity for everyone throughout the Rogue Valley, we recognize that climate change does not and will not affect everyone equally. Those members of our community already vulnerable or marginalized will likely be hit sooner and harder by the impacts of climate change in the Rogue Valley and will have fewer resources to adapt to a changing climate. We believe our collective efforts to combat climate change-such as municipal Climate and Energy plans-need to account for this. Those most directly affected-including low-income members of our community and those with limited access to political processes-need to be at the table and a part of the process of developing solutions and strategies to address climate change. As such, we appreciate the emphasis put on collaboration and community engagement in the Conservation Commission's recommendations to the City Council, and we look forward to engaging our members, supporters, and the broader community in the planning process. We believe Ashland is in a unique position to take bold leadership as a community in responding to climate change, and we are proud to see Ashland moving forward with that process. Oregon Action and our members look forward to supporting the City in these efforts, and to participating and engaging in that process. Sincerely, Alex Budd Oregon Action Minutes for the City Council Study Session September 15, 2014 Page 1 of 2 MINUTES FOR THE STUDY SESSION ASHLAND CITY COUNCIL Monday, September L5, 2014 Siskiyou Room, 51 Winburn Way Mayor Stromberg called the meeting to order at 5:32 p.m. in the Siskiyou Room. Councilor Morris, Rosenthal, Marsh, Voisin, and Lemhouse were present. Councilor Slattery was absent. 1. Look Ahead review City Administrator Dave Kanner reviewed items on the Look Ahead. 2. Public Input (15 minutes maximum) Winston Friedman/935 Oak Street/Thanked the Council for considering the resolution supporting fossil fuel divestment. Southern Oregon Climate Action Now (SOCAN) was a group that strongly supported divestment and were concerned with the bigger picture of climate change. He read from a document submitted into record on the impacts of climate change, fossil fuel extraction and how major corporations negatively affected sustainability efforts. Ken Deveney/206 Terrace Street/Spoke in support of the Conservation Commission's Community Sustainability Framework proposal and explained mental health was a major component of climate change preparedness. Many people will experience stress that could result in an increase of domestic abuse and crime due to the heat. The climate change will affect illness, food prices, changes in employment, and acute trauma from extreme weather events. The National Wildlife Federation collaborated on a report regarding the psychological effects of climate change that stated the affects of global warming will require a large-scale mental health care response and no one was prepared. 3. Discussion of a Resolution in support of fossil fuel divestment City Recorder Barbara Christensen explained the resolution would not change the City's investment policy and only support the position Southern Oregon Climate Action Now (SOCAN) was taking on fossil fuel divestment. SOCAN was asking Council to move the resolution to a regular Council meeting for approval. If approved, the resolution would go to the Oregon Short Term Board and the Public Employee Retirement System (PERS). Ms. Christensen used the City of Eugene's resolution on divestment as a template for the one before Council. Council noted an opinion editorial from State Treasurer Ted Wheeler that concluded divestment was not in the best interest of the state. That made the resolution more of a symbolic gesture. However, an earlier conversation with Mr. Wheeler and the governor revealed they needed the support of municipalities in order to give the resolution power. The Mayor expressed concern regarding unintended results due to divestment. Council supported putting the resolution on a formal agenda. 4. Community Sustainability Framework proposal from the Conservation Commission Management Analyst Adam Hanks provided history on the Conservation Commission's interest and efforts regarding sustainability. With the approval of the Operational Sustainability Plan Framework, Plan Format, and Process Outline November 2012, the Commission shifted focus to a community sustainability plan using the STAR Framework. Conservation Commission Vice Chair Roxane Beigel-Coryell defined sustainable as something able to be Minutes for the City Council Study Session September 15, 2014 Page 2 of 2 used without being completely used up or destroyed involving methods that did not completely use up or destroy natural resources or able to last or continue for a long time. A sustainable community included common elements that were healthy environment, strong economy, and the well-being of the people living in the community. She shared several guiding principles of sustainable communities. Conservation Commissioner Jim McGinnis provided an overview of the STAR Framework that consisted of Guiding Principles, Goals, Objectives, Measures, and Actions. STAR was Sustainability Tools for Assessing and Rating communities. The STAR Framework was a current and comprehensive way to track and assess sustainability. The STAR approach represented a multiyear process and was not a plan. The Guiding Principles served as a reference point when planning or taking actions. The STAR Framework was based on the following goals: • Built Environment • Climate & Energy • Education, Arts & Community • Economy & Jobs • Equity & Empowerment • Health & Safety • Natural Systems Each goal contained several objectives with measurable items and best practices. Vice Chair Beige]-Coryell reviewed a matrix of goals and actions taken by the City and Southern Oregon University (SOU) and submitted an example of Climate & Energy and Health & Safety into the record. Commissioner McGinnis further explained the Conservation Commission had followed through on the 2011-2012 City Goal of developing a concise sustainability plan for city operations and community. The city operation was underway and the next step was the community portion. The STAR Framework created a network with other communities. The Conservation Commission was asking Council to adopt the framework as a successor to the Valdez Principles, instruct staff to provide regular reporting within the STAR Framework, and allocate adequate resources to administer the program. Resource allocation would start with half of a Full Time Equivalent (FTE) employee for the 2015-2017 budget and grow to a FTE in the 2017-2019 budget. Council comments thought the STAR Framework was too broad and complex, wanted the focus on Climate and Energy only while other comments noted STAR could serve as a good resource. Council directed the Conservation Commission to bring back a proposal on what steps they would take to develop a Climate and Energy Plan. Meeting adjourned at 7:18 p.m. Respectfully submitted, Dana Smith Assistant to the City Recorder +IC I T Y 4 F S LAND M A z f r MIN Application for Economic Development, Cultural, Tourism and Sustainability Grants DUE March 27, 2015 by 4:00 pm One (1) signed hard copy to City of Ashland, Finance Department Attn: Kristy Blackman Titled: Grant Application 20 East Main Street, Ashland, OR 97520 and one electronic PDF copy to 44risty k~lac~rnnn ~~a~~~ian~ c~r.~,~ Applicant/Or ganizat'ron Geos Institute Mailing Address 84 Fourth St. Ashland, OR 97520 Contact Name - Tonya Graham Contact -mail t.ontact Phone No 541-482-4459 x301 Contact Name #2 Marni Koopman Contact E-mail #2 marni@geosinstitute.org Contact Phone No#2 541-482-4459 x303 Federal Tax ID 93-0880205 IRS Class (Exemption) 501 c(3) Total Grant Request $27,040 (S5,000 min) Application Submittal Checklist In addition to the completed application form to be mailed and emailed, all submittals must contain the following; 1. List of all board members, their occupations, and years on the board; 2. Organizational client demographic profile; 3. Grant program budget (for activities/programs/events that are part of this grant application); 4. Organization 5010 letter verifying your no-profit status; 5. Organization corporate bylaws; 5. Organization's most recent Form 990 IRS filing (summary page only); 7. Organization's previous year financial statement summarizing expenses and revenues. Page 1 of 17 Application for Economic Development, Cultural, Tourism and Sustainability Grants 1. Briefly describe the purpose and objectives of your organization and mission statement (from byla:vs, articles of incorporation or board adopted mission statements). 'I lie Geos Institute uses science to help people predict, reduce, and prepare for climate change. We engage through three initiatives. The initiatives address the challenges of climate change in freshwater systems, communities, and forests. ClirnatelVise engages local communities in preparing for climate change. We provide the science needed to identify, likely future climate conditions and local impacts, facilitate the development of an actionable, integrated plan, and work across sectors to create co-benefits and new avenues for communication. We have worked in many, cities and counties, including the Rogue and Klamath Basins OR. Austin TX, Fort Collins CO, Missoula County MT and San Iu is Obispo County CA. Green Solutions addresses the needs of people and fish as they relate to freshwater systems. We have completed 25 restoration projects improving over 1.100 miles of stream in the Rogue Basin over the past ten years. '['his program also addresses municipal water needs using watershed restoration to improve the quality and dependability of municipal water supplies. Ranking on Forests works to slow climate change by protecting the carbon sequestered and stored in forests, especially the carbon dense forests of the temperate rainforest region. 2. Provide a short history of your organization. 'I Ile Gros Institute began in 2005, as a merger bettiveen the grassroots watershed protection organization.. called I leadwaters, Inc. and the \Vorld GV'ildlife Fund's Klarn<ath-SiskiVOU Field 0111ce. Then named the National Center for Conservation Science and Policy, the organization worked on lbrest and river restoration and protection. Soon, climate change emerged as the greatest threat to natural systems and we realized that our communities are also threatened. Because the solutions to climate change stem from protecting Our most vital resources, our' Banking on Forests and Green Solutions programs became even more vital. In 2008 we added ClimateWise to Our suite. of programs to protect both human and natural systems from the accelerating impacts of clin'iate change. 3. Describe the purpose and objectives of this grant request. We are applying for s Sustainability Grant for this project. The purpose of this grant request is to kick-start a highly collaborative Climate and Energy Action planning process for the eommruiity ofAshland, pursuant to the steps of the plan put forward by the Conservation Commission during a March 15, 2015 Study SessiOn with City COUncil (tile steps are listed in the next section of the proposal, and also available at this link littp://wtivxv.,,islilzrnd.or.us/SIB/tiles/031515 Climate-Energy Plan_CC.pdfj. The specific objectives include: • Convene an informal group of NGO and university partners that will help to design and implement the Climate and Energy Action Planning Kick-off Event. Potential partners include Rogue Climate, ACCESS, Chamber of Commerce, SOU Center for Sustainability, Lomakatsi, Clean Energy Works, Rogue F"nergy Alliance, Oregon Community Foundation, and more. We would welcome City Staff, Council, and/or Commission participation in the leadership group as well so this effort can be coordinated with the next steps in the Climate and Energy Action planning process. The leadership group convened for this project can be engaged, if appropriate, to participate in the City/Citizen Oversight Group (see Step #2 in the next section) as part of the Climate and Energy Action planning process, but the decision to do so rests with the Conservation Commission and/or City Council. For purposes of this project, this leadership group is limited to the roles outlined in this proposal. Page 2 of 17 • Create outreach materials, including printed and online interactive materials, that summarize local climate change projections, results from the City's Greenhouse Gas (GHG) Inventory, results from the Renewable Energy Assessment for Jackson and Josephine Counties from 2011, and other relevant reports and data that help to set the stage for why action is needed and what direction we might want to take. Please see examples of some materials created for efforts in Austin, TX (lit i pi L•li.i . , . ~ t-ei,r,ut_'h-% ci) and Fort Collins, CO (video can be found at cl i', • Create outreach materials, including printed wid online interactive materials, with positive messaging about new approaches to cnetgy, conservation, renewable energy opportunities, emergency preparedness (for Hooding, witdfire drought, and heat waves), and a positive future, for Ashland. These materials would also include links to surveys to get public input on actions our community can take, desired targets for greenhouse gas emissions reductions, and collective: prays that the public and businesses can get involved and challenge one another. We will also create a tracking page for voluntary reporting of actions taken and GHG pollution avoided. We will develop catchy names and branding for the effort to make sure the public recognizes it as an attractive and cohesive effort that people want to engage with. There may be opportunities for competition, prizes, and community recognition this will be decided by the leadership group. • I loll a I-day public workshop and event to: showcase 6I16 inventory results c feature speakers from another community with positive examples of energy and monetary savings 'D share information on climate change trends at the local level, including risks to vulnerable people and resources o consider options for future greenhouse gas emissions targets for Ashland o brainstorm and prioritize innovative approaches to energy conservation and renewable energy production develop ideas for cross-sector approaches that also address many ongoing societal issues in Ashland c develop new ideas for en-agement, funding mechanisms, and action o showcase local foods, goods. and services that save energy and support the local economy Compile information collected during the outreach steps and the public workshop to inform the next steps in the Climate and Energy Action planning process, as outlined by the Conservation Corrunission. The information will be delivered to the Conservation Commission and City Staff, as needed. Prior consultation with the, Conservation Commission and City Staff will be conducted to ensure that any data and information collected is provided in the most useful manner for ongoing work on Climate and Energy action planning. 3,1 If your grant request is for date specific events, programs or activities, please complete the following table' (If completing electronically, double click the table to enter data) Program/Event Title Anticipated Funding Total % of Dates of Event Request budget 100% including Ashland Climate and Energy Action Kick-off and Fall 2015 $28,540 salaried time for Workshop (Catchy name TBD) planning and implementation 3.2 Describe how the program/event/activity listed above meets the purpose and objective of this grant request, i.e. connect event/activity to overall purpose/objective of grant request. 'f°ile Climate and Energy Action planning process for the City of Ashland was presented by the Conservation Commission during a City Council study session on March 16, 201 S. Ali outline of the proposed project is available at this link http://www.ashland,or.us/Sl13/filesl031615 C;lirnate_Energy--Plan CC.pdf. The process includes 8 steps that take place during the first year, and d more that continue into the future. Our project aims to further the city's sustainability goals by supporting that planning process by assisting with implementation of steps #2-4. Page 3 of 17 The 12 steps in the Climate and Energy Action planning process are as folloNvs: (from the Climate and Energy Action flan framework presented by the Conservation Commission for City Council on March 16, 2015): 1. Greenhouse Gas Inventory -The City conducts or contracts a greenhouse gas inventory that includes a subset for city operations (transportation is included); this inventory will also benefit the city operational sustainability plan that has already been adopted by City Council. The purpose of the GHG inventory is to identify' local sources of GHG emissions so we can direct resources in the most efficient and cost- effective manner possible. 1 Leadership - Appoint a City/Citizen Oversight Group, which will create a Technical Advisory Committee to set scientifically valid GHG emission goals, engage community members. interface with other groups; conduct outreach, guide strategy development, and prioritize actions. City Staff will support the Oversight Group as needed. See Appendix III for more information. 3. Set Emissions Reduction Targets - Many communities use targets set by state government, while others decide on more strincnt targets for their community. The Technical Advisory Committee will investigate and recommend appropriate targets for Ashland. 4. Public Outreach - Hold a public kick-off event that informs community members about the effort. engages them on the issue, Collects their input on areas of highest priority, and showcases positive stories and successes in energy Savings and renewable energy. j. Engage Local Experts - Convene sector specialists to develop initial lists of strategies and prioritise them in a collaborative manner, based on cross-sector discussions of synel-gies, short- vs. long-term goals, areas with the greatest/fastest potential energy savirlgs, most vulnerable resources and populations, and issues of equity and local values. 6. Consult with City Council and City- Staff-- Hold a working session with City Council and City Staffto further refine and prioritize emissions reduction strategies and climate change preparedness strategies. City to identify a number of actions for immediate implementation. 7. Finalize the Plan - The plan should include emissions targets, a timeline, high level goals. specific strategies, and actions that are organized by short and long term implementation horizons. The plan should include an implementation plan that specifies who is responsible for specific actions, a monitoring plan to assess progress, and periodic updates to the plan. 8. Get Feedback - Hold an open forum workshop(s) to share information and collect feedback. Also use online forums, local TV and radio, printed media, and other outreach tools. Report the results online in other venues, as appropriate, with recap of the process, detailed strategies, and timeline. 9. Implement - Implement strategies in phases, following implementation plan. 10. Assess performance- Measure and report on results periodically (every 1-3 years) 1 1. Reassess - Revise based on new information, ongoing trendy, new technologies, in(] results from monitoring. Develop additional measures to 17rotect the community from climate change impacts. 12. Educate - Continue with public outreach and education for Sustained efforts. This proposal would provide support from a large group of NGOs arid Southern Oregon University for steps 42-4 ofthe city-sponsored planning process. Specifically, many participants in our leadership group could become part of City/Citizen Oversight ht Group convened in Step 42. We would initiate discussions of greenhouse gas emissions tar,=ets in the leadership group and also survey participants at the event and in an online Survey, contributing to Step 43 - Set greenhouse gas emissions targets. The event described bolo vv would complete Step #4 - Public Outreach. All information collected during this project would feed into the ongoing Climate and f:nergy Action planning process that is City-supported, so we would consult with City Staff to ensure compatibility and information transfer, as needed. The kick-off event is an important step in the Climate and Energy Action planning process, as it • informs community members about the community planning process, • provides a venue for collecting input and feedback, • stimulates the development of innovative ideas. • allows us to gauge peoples' level of support for different actions, and • provides a strong educational component. Page 4 of 17 This event will also provide a venue to showcase the successes and energy savings that Ashland has already accomplished, as well as those of similar communities from other areas. We will highlight positive stories of energy and monetary savings, job creation, environmental benefits, and social benefits. We will invite leaders from other communities, such as Fiend, I'utgene, Austin, and/or Fort Collins to speak at the event and answer questions about their climate and energy plans, implementation, performance tracking, and lessons learned. Events focused on climate change can be daunting, as the topic is quite serious and people experience intense emotions of loss and sadness when they begin to really understand the consequences. The Geos Institute and Rogue Climate have both had extensive experience in planning and implcinenting events that are built around the topic of climate change. We have learned that such events need to focus on positive solutions and keep participants erigaged in a positive and constructive manner, yet still create space for grief to be acknowledged and held. We envision that the Ashland Climate and Energy Action Rick-off event will showcase positive examples from around the country while also focusing on the. values that are important to our community - including local food, the environment, water, and good health. The event will be active (not a lot ofsitting and listening), will allow for small groups to get to know each other and work together, will feature good food from local sources, and will focus on innovation and collaboration as the solutions to climate change. We see this as a very positive event that will result in ne,.v relationships being formed throughout the community. Rogue Climate is led by young and energetic leaders in our cornniunity their enthusiasm, passion, and energy is contagious and will create a positive platform for real action out this issue. Geos Institute has extensive experience organizing large groups in ways that facilitate innovative thinking and the organization of ideas for future, use. Tile specific speakers, facilitators, format, and opportunities for outreach are still to be %vorkcd out with our leadership group. The Climate and Energy Action planning process vas purposefully designed to be highly collaborative and participatory, with a focus on innovation and fun, 'file leadership group will determine how to engage the community in new and effective ways. Before and after the event, We will provide nUrnerous crigagernent opportunities including a Facebook page and other social media, online surveys, and outreach materials with our contact information for people wanting to get more involved. We will create an outline energy use tracker that allows residents and businesses to report changes they make and their links to energy savings over time. We will create a database with the names, contact information, specialized areas of interest and expertise for each contact; and what they are trilling to contribute (time, money. design help, tabling, physical labor, etc.) during this phase of the project and over the coming years. Ashland is a generous and cohesive cotnnurnity that is ready for action oil climate change - we will begin to harness rued organize that energy and goodwill so that it is ready to be deployed during flrture phases of the Climate and l-'nergy Action Platt. 4. Utilizing the list of eligible activities provided in the 2012 Policy for Economic, Cultural, Tourism and Sustainability Grants (attached), please describe how your grant application meets the listed eligible activities for each funding category(s) requested in this application. The proposed activities meet the eligible activities for Sustainability grants in numerous ways. First, the Climate and Energy Action Planning process for the community of Ashland needs to quickly get started in order- to meet its aggressive timeline (planning in year 1, impiernentation starting in year 2). The proposed activities will kick- start the planning process using education and outreach as the mechanism to develop new and innovative strategies for energy conservation and renewable energy. The proposed activities will assist local businesses in conservation and renewable energy production, as they will be one of the target community sectors for brainstorming and for gauging where their needs and interests lie. The business sector will also have a role in the. NGC) and university leadership group, especially through the Chamber of Cominerce. Businesses, such as solar installers, building contractors, architects, electric car dealers, and others, will be able to participate in the process and share information about netiv innovations and services they can provide for the community. Finally, the community workshop will feature local and sustainable- foods and other products and show how their carbon footprint is much lower than foods produced elsewhere. Page 6 of 17 5. Describe how your grant proposal meets and accomplishes the desired outcomes detailed in the Criteria far Evaluation section for each of the Grant categories applied for from the 2012 Policy for Economic, Cultural, Tourism and Sustainability Grants. The outcomes of this project meet the Criteria for Evaluation in a variety of ways. First, the project will brim the conutnnity together to acknowledge the severity of the threat of climate change and the need to take immediate and drastic action to cut GHG emissions in a collaborative and positive way. The immediate effects of the workshop will be a renewed and increased motivation for individuals to reduce their carbon footprints at home and in their businesses, plus ongoing reminders, motivators, and information that helps them continue to do that. 'File workshop vvill result in new and innovative ideas for how to make Ashland a more sustainably city, what CA K; emissions targets to ain for, and how local residents envision the path to meeting those targets. 'rile information, new contacts, and new leadership that will be gained from the kick-off event are directly relevant and transferable to continuing xvith the Climate and Energy Action plannirg process through spring, 2016, as well as during the implementation phatie starting immediately afterwards. The most measurable outcome will be GIIG emissions reductions over time, with any savings linked to energy conservation and/or renewable energy production. State tat-gets of 10% below 1990 levels by 2020 and 75% below 1990 levels by 2050 are targets often adopted by local communities, but Ashland may choose to adopt more aggressive targets. Repardless of which targets are adopted, tracking of Ashland's progress over time will be vital to determining which actions are most effective and whether or not we are on track to meet our goals. "these goals take time and will not be tracked during the implementation of this specific project (which only encompasses Steps #2-4 of the Climate and Energy Action planning process). Our project will lead to lessons and experiences that can be tracked over time to learn about effective actions to reduce GHG emissions at the local level. We will also learn what actions create co-benefits for other issues, such as air pollution, hunger, homelessness, and compromised health. Actions that are developed to address these issues and to save energy and install locally-produced renewable energy undoubtedly will support local business, create jobs, and increase locally-sourced goods and services. These long-teen benefits cannot be measured in the time of this project, but they will be central to the innovation and discussion at the workshop. The outreach materials and presentations at the workshop will provide education on climate change, climate change vulnerabilities, and positive approaches to increasing community resilience to the general public. We will shrive to reach diverse audiences including local businesses, horneowners, renters, students, decision makers,. healthcare providers, NGOs. retirees, row-income residents, and mantic others. 6. If you do not receive the full amount of your request, describe how your organization would use a smaller amount of funds in each of the categories being applied for. With true full amount, we will contribute to Step 2 Creating the City/Corrtn unity Oversight Group and Step i= - Setting GHG Emissions Targets and also complete Step IN - Public Outreach. With a lesser amount, we can still hold a kick-offevent, but it would tic a smaller and less ambitious event created primarily by Rogue Climate and the Geos Institute, uviih input also from the Conservation Commission and ACC FSS. This event would get the Climate and Frierey Action plan going in a positive and collaborative wa%, but it would not create as nructr initial momentum, engtrgentent, and community buy in for the planning process as our full proposal. This would leave more work for those tasked with the next steps in the Climate and Energy Action planning process. 7. Describe what, if any, actions your organization takes in developing and securing other revenue sources beyond the City of Ashland Economic, Cultural, Tourism and Sustainability Grants. (both one time and ongoing revenue sources) The Geos Institute supports its programs through foundation grants, government grants and contracts. and individual donors. In addition. we have a consulting arm that provides climate change support for communities throurgh a fee-for-service format. Most of our individual donors reside in the Rogue Valley and we N ould put out a special request for contributions to help fund this project. Page 6 of 17 8. What percentage of your organizations total annual revenue would come from this grant if it were fully awarded? The funding requested represents a little over 1% of our organization's annual budget for 2815. It is important to note, however, that of our roughly $2.1 million budget, over $800,000 of that budget is expenses related to a restoration project for which we are serving as fiscal agent. Our core budget for staff is typically around $ I million to $12 million. This grant represents over 2% of our core budget. While the Geos Institute needs this grant to provide this particular service to our community. it does not need this grant to stay operational. We would very much like to work in our own hometown of Ashland by providing the services and expertise that ,ve provide for other communities. This includes helping to get climate change plannin- off the -round and supporting residents and city staff through the engagement, education, and action components of an effective response to climate- chin-e. We believe Ashland can position itself as a real leader in this area <md we would like to help since our core competencies align so well with the City's sustainability goals. 9. Describe your organization's strategies and efforts to minimize administrative overhead costs for your organization in general and for the specific programs, activities or events being applied for in this application, including collaboration and/or leveraging of other partner organizations. The Geos Institute incurs minimal overhead costs throtrgh ntrmer-Otrs measures. We own our oven buildim., in Ashland reducing the cost of office space. We rent out offices to the Southern Ore-on Land Conservancy and also rent our event space to community grinrps and individuals during evenings and weekends. Administrative costs are shared among programs to keep them low. Finally, we have under=one an energy audit and taken action to tifhtett up our building and reduce our energy use and the costs associated with it. Given that we are located in Ashland, there will be no travel expenses for our staff associated with this particular project. 10. Describe data collection and reporting systems that will be utilized for gathering the data for the outcomes on the use of the grant funds (please reference criteria for evaluation and reporting requirements detailed in the 2012 Policy for Economic, Cultural, Tourism and Sustainability Grants) One of the most important components of this effort, and of the Climate and Energy Action planning effort as a whole, is the tracking, documentation, and data collection aspect of the work in order to determine the most effective strategies for reducin- GHG emissions and also to determine that GI-IG emissions efforts are creating co-benefits across diverse community sectors. We will start this effort off on the I-i-ht track with careful documentation and analysis ol'the steps that we lead, which will then be transferred to those who lead the other steps of the process as well. We will track the following variables. • Grant fund allocations for staff time and services, stich as food, venue rental, and supplies • ?titunbcr and contact information for people participating in each leadership meeting, • dumber and contact information for people participating in the public workshop • Number (and contact information, when possible) ofpeople. participating online in Open forums, surveys, and other outreach • dumber and contact information for business representatives involved in meetings and workshop • Information on what individual people and businesses have to offer to the effort (time., money, skills, etc.) • Survey information from participants oil preferred levels of GHG emissions targets for Ashland • Workshop outcomes, including prioritized lists of potential actions that reduce GHG emissions, as well as their potential costs, co-benefits (such as cleaner air or reduced home heating costs for low income people), target populations, potential partners, and other information that is vital to implementation. • Immediate business growth as a result of the workshop, including solar installation contracts, electric car leases, and/or home ener-v consultations (for example, alter a hearth storytelling event, True South Solar reported immediate sales of new solar installations directly linked to the event) • Self-reported energy savings and specific actions that residents have taken - this will be implemented during this project and will continue as one of the data collection resources during Climate and Energy Action plan implementation over the coming years Page 7 of 17 11. What are the current insurance coverage limits on your organizations general liability insurance coverage for bodily injury, personal injury, and property damage? Bodily Injury: 20,000 Personal Injury: 1,000,000 Property Damage: 500,000 Per Occurrence: $100,000 Aggregate Limit: $2,000,000 Thank you for your time and efforts in preparing this information for the consideration of the Grants Committee. I understand that a grant may be conditioned on submission to the City of a Certificate of General Liability Insurance in the amount of up to $2,000,000 naming the City of Ashland, its officers and employees as additional insured. I also certify that the undersigned has legal authority to submit the above information on behalf of the organization named above. Name (print) jt ~1 A. r to=n Name (signature) Z Title t° Citi1l vE i ~tC! Page 8 of 17 ADDITIONAL SUBMITTAL INFORMATION & REFERENCE MATERIALS The following requirements and forms are provided to assist applications in submitting a complete application package. "Ise of the form templates provided is not a submittal requirement, but rather an optional tool for the applicant to use if ley choose to provide the required information in this format. i. Grant Requirements (from 2012 Policy for Economic, Cultural, Tourism and Sustainability Grants) A. Grantee shall be registered as a 501(c) non-profit B. Grantee shall be a non-government entity C. The minimum grant award is $1,000 per category and $5,000 per grant application D. Grant award shall be utilized consistent with the associated applicant proposal and shall be primarily oriented to the grantee's Ashland activities and programs. Grant funds may also be utilized for a proportionate share of Grantee's overall administrative expenses. E. An applicant can apply for grant funds from more than one category, however, it is the responsibility of the applicant to specify the categories and funds requested for each category and clearly describe how the proposal meets the criteria for each category. F. Grantees must submit the application to the City prior to the deadline, which is established each year by the City's Administrative Service Department. Absolutely no late applications will be accepted therefore, applicants are advised to have a backup plan to ensure that the application is not late. G. Incomplete applications (see application cover page) will not be forwarded to the grant review committee for consideration. H Materials submitted beyond those required and listed on the application cover page and application form will not be forwarded to the grant review committee as part of the application packet. li. Grant Submittal A. Grant applications for FY2015-16 are due on March 27, 2015 by 4:00 PM. B. Completed application packets can delivered in person to the Utility Billing offices at City Hall (20 East Main St) or mailed to; City of Ashland C!- Kristy Blackman 20 East Main St Ashland, OR 97520 C. Questions regarding the FY2015-16 Grant Program can be directed to Kristy Blackman, Finance Dept Administrative Assistant by phone at 541-552-2012 or l isty 1.1 I C; _Us *If yorlr organization is being sponsored by or legally affiliated with a registered non-profit, a letter from that organizations Board of Directors recognizing the affiliation and a copy of the 501 (c) verification of the sponsoring non-profit Page 9 of 17 Tourism As required by State law, a portion of the grant program funds must be awarded and utilized for specific tourism related activities. The grant program typically awards tourism funds in excess of the minimum amount required to meet Oregon Revised Statute (ORS) definition and criteria relating to tourism promotion. Applicants requesting grant funds for activities that meet the ORS definition and criteria of tourism should highlight how the grant request meets the following ORS criteria, § 320.300, (6) 'Tourism' means economic activity resulting from tourists. (7) 'Tourism promotion' means any of the following activities: (a) Advertising, publicizing or distributing information for the purpose of attracting and welcoming tourists; (b) Conducting strategic planning and research necessary to stimulate future tourism development; (c) Operating tourism promotion agencies; and (d) Marketing special events and festivals designed to attract tourists (10) 'Tourist' means a person who, for business, pleasure, recreation or participation in events related to the arts, heritage or culture, travels from the community in which that person is a resident to a different community that is separate, distinct from and unrelated to the persons community of residence, and that trip: (a) Requires the person to travel more than 50 miles from the community of residence; or (b) Includes an overnight stay. Page 10 of 17 Applicant Organization Board Member Information Reporting Sheet Nam Address Phone Occupation Title Term of Office Ken Crocker 134 Nutley St., Ashland, OR 541/488- Computer Consultant 13-15 97520 0677 Systerns Architecture Linda Schaeff 904 I1illview, Ashland, OR 97520 541/778- Organizational Consultant 13-15 _ 3130 Development Stephen Sendor 413 Clinton, Ashland, OR 97520 541/201- Publishing Ot ner and Consultant 14-16 0277 Joanne Eggers 221 Granite, Ashland, OR 97520 541 /482- I'eachim, Forner Ashland Parks )3-15 3305 Commissioner Bill Bradbury 1256 Newport Ave. S`wl', Bandon, 541-347- Nat. Resource formerly State Senator and 14-16 OR 97411 9377 Consulting and Orcgon Secretary of State Public Official {1999-2007) Jini Furnish 4900 llornbeam Dr., Rockville. 240-271- Consultincl formerly IJ.S.1 .S. Forest 15-17 _ MD 2085; 1650 _ Forester tit~aervisorc` I)cptnti(:lief _ Jim [nee ~~-108 Milarr.pa Rd., Azalea, OR -`i41-837- Imports and Business Owner ~ 13 15 97410 3636 Ranchint _ - - - - Steve Schein 2208 Lupine Ashland, OR 97526 541(944- Educator and Associate Professor in the 14-16 0526 Author School of Business Camila Thorttdike 369 Granite, Ashland, OR 97520 5}1;951- Grassrools Executive Director of 15-17 2619 Organizing, and Oregon Climate raistttg_ Fund i i 1 r Page 11 of 17 City of Ashland Customer Demographic Profile The primary goal of the grant award process is to allocate funds to organizations that are providing economic, tourism, cultural and/or sustainability programs, services or events that reach a demographically diverse customer base, both locally and from outside our region. The following questions are intended to provide guidance for the possible types of customer demographics that would help the grant review/award sub-committee understand the customer types that your application would likely reach. * if your organization tracks this data or other related data, in other formats, please feel free to submit that format directly. This form is provided as a template and is not required to be completed in this format, but customer demographic information is an application submittal requirement. Organization Name: -Leos Institute Program/Event Name:_Organizational programs For the Twelve month period of-March 1, 2014 February 28; 2015 1. Customer Age (percentage) IL Staff Residence (percentage) Youth 0 to 17 years Ashland 67 Adult 18 to 30 years Rogue Valley __33 Adult 40 to 64 years Other -0 Adult 65 and over Unknown 100 Total 100 Total 'I. Customer Residence (percentage) Ashland Rogue Valley 10 Other (within 50 miles) ,_10 Other (greater than 50 miles) 80 III. Of the Customers identified above, what percent do you estimate stayed overnight to attend your program, service or event? _5 As a nonprofit organization focused on translating climate change science for decision-makers and land managers, our work takes us all over the country. Some of that work affects our local area in Ashland and the lamer Rogue Valley, but we do not track customers in the standard tivav that we WOUld if we operated a tourism based business in Ashland. Our `customers" are communities and resource ninnagernent districts, both of ,xhich represent a lame number of people, but are not quantifiable. 'T'hat being said, some of our board members come in from out of tOW11 to attend board meetinos and we host events that bring visitors to town over the course of the year. Because of our reach beyond the Rogue Valley, however, we are able to highlight Ashland's progress on sustainability° issues thraugh this project and bring greater attention to the City's role as a sustainability leader in the region in a gray that would not be possible with a more traditional customer base. Page 12 of 17 CITY OF ASHLAND GRANTS PROGRAM BUDGET Please use this form to identify costs associated with the program, activity or event that you are requesting -ands for. This form is provided as a template to use. If your organization tracks grant related financials in a different reporting format, please submit in that format if you choose. APPLICANT/ORGANIZATION: Geos Institute PROGRAMlEVENT TITLE. Climate and Energy Action Planning First Steps and Kick-off Event PROJECT PERIOD: July 1, 2015 to June 30, 2016 REVENUE City of Ashland Grant Funds $ 27,040 Jackson County Funds /Identify: Other State or Federal Funds /identify: $ _ Other Funds /Identify - Local individual donor contributions $1,500 $ Other Funds (coat) TOTAL REVENUE $28,540 EXPENDITURES A. PERSONAL SERVICES (List costs by job title or functions _ Total Salaries % of time to project $21,060 1. Geos Institute Project Manager 5% 2. Rogue Climate Project Manager 7% 3. Geos Institute Media Outreach Coordinator 2% 4. Rogue Climate Media Outreach Coordinator 2% Total Benefits $4,980 1. Geos Institute Project Manager 2. Rogue Climate Project Manager 3. Geos Institute Media Outreach Coordinator 4. Rogue Climate Media Outreach Coordinator TOTAL PERSONAL SERVICES $25,040 B. MATERIALS & SERVICES; Printed materials $500 Online Prezi consulting $500 Venue --this could be lower if City venue is used $1000 Food - We will supplement this line item with donations from local businesses $500 TOTAL MATERIALS & SERVICES $2,500 TOTAL EXPENDITURES $2$540 Page 13 of 17 2012 Economic, Cultural, Tourism and Sustainability Grants Policy Program Goals, Categories, Criteria, and Requirements The City of Ashland collects a Transient Occupancy Tax, from people who stay in overnight lodging within the City limits. Over half (58%) of those funds are reserved for the City's General Fund and are used to support Police, Fire, Community Development, and Municipal Court. Slightly more than a quarter (26.67%) of those funds are used to support the tourism industry. The tourist funds are either allocated directly to groups that market Ashland to tourists or are spent on capital facilities that enhance the tourism experience within the community. The remaining funds are dedicated to the City's annual grant program. The amounts that go to each of these programs are allocated prior to the beginning of each fiscal year by the Ashland City Council; generally in February. The City of Ashland reinvests a portion of the funds generated by the Transient Occupancy Tax (TOT) in community non- profits through an annual grant program. Through the grant program, the City is purchasing specific services from non- profits that it might otherwise provide directly. The grant program has four basic goals: • Economic Development. The grant program will support the creation, retention, and expansion of businesses and other ventures that enrich our community by creating goods and services that provide employment opportunities while maintaining and enhancing the overall quality of life. The 2011 Economic Development Strategy provides both policy level and action level guidance for eligible grant application programs and activities. • Cultural Development. The grant program will support increased diversity of and accessibility to the creative arts and cultural opportunities in Ashland for citizens and visitors and will support the visitor economy, maintain and promote job growth in this sector and enrich the overall quality of life in the community. • Tourism. As a long standing pillar of Ashland's econorny, tourism programs support programs, activities and events that act similarly to more traditional traded sector activity in that dollars from outside the community are brought in and circulated locally to the benefit of our local businesses. • Sustainability. The grant program will create and support programs and activities to further support efforts to ensure Ashland is environmentally, economically and socially resilient as a community. 1. GRANT CATEGORIES Non-profit organizations applying for grants must identify the category of funds that their application meets and will be evaluated and scored by the sub-committee using the attached scoring sheet. Applicants may request funds from multiple categories, but the justification for applying in multiple categories needs to be clearly spelled out in the application, A. Economic Development Grant allocations in the Economic Development category will be made to support and implement the City's Economic Development Strategy. Eligible activities include: 1. Specific implementing actions or programs identified in the economic development strategy. Those activities can be found at ht':, ndf C i ind [-Corm: _ on pages 8 through 22. 2. Programs and activities that foster and support the creation, expansion or retention of existing businesses in the community that • rely on and earn a competitive advantage from innovation, creativity, design, proto-typing and technology • produce specialty and value added goods or services with a market beyond our local economy 3. Programs and activities that improve the coordination, communication and collaboration among local and regional economic development partners. 4. Programs and activities that promote and/or provide and increased availability of investment capital for local business. 5. Programs and activities that improve local educational & technical skills to match local business workforce needs. Criteria for evaluation The City seeks to accomplish the desired outcomes from the economic development strategy (page 23) through the grants, and therefore these outcomes will be used to evaluate applications. Applications for the Economic Development Page 14 of 17 Grants will be evaluated based on the following criteria: Likelihood that the proposed activity will increase or support an increase in total employment within Ashland. • Likelihood that employment and businesses being served by the grant will be added in enterprises that rely on innovation, creativity (etc.) or produce a specialty good or service for export. • Likelihood that the proposed activity will support and assist existing businesses within Ashland in expanding or remaining in the community. • Likelihood that the proposed activity would support and foster an increase in jobs that are at or above the median income for Ashland. B. Cultural Development Cultural development grants are intended to support the retention and growth of Ashland's unique cultural offerings, both to residents and tourists alike. Leveraging and expanding Ashland's cultural assets such creative, performing and visual arts, historic preservation and education, brings creative community prosperity and adds to the overall quality of life of the community, Ashland's visitor economy also thrives on the cultural and performing arts sector, so increasing the diversity of cultural opportunities for visitors strengthens the tourism economy overall. The City's grant program is designed to strengthen existing cultural activities, increase the number and diversity of cultural activities,. maintain and expand job growth in this sector, and increase both resident and visitor access to these activities. Edible activities include: 1. Programs or activities that create cultural offerings unique from existing local offerings, activities or programs, 2. Programs or activities that ensure the long-term success of local cultural groups. 3. Expansion in size or scope of existing cultural offerings, activities or programs. 4. Expansion of audience access to those existing offerings, activities or programs. 5. Support services targeted to existing or proposed cultural offerings, activities or programs. Criteria for Evaluation. Grant applications for cultural development monies will be evaluated based on the following: • Likelihood that the proposed activity will diversify the number, type, or availability to cultural service, activity or program proposed compared with existing local cultural opportunities. • Likelihood that the proposed activity ensures long-term access to an important aspect of the visual or performing arts or other local cultural attraction. • Degree to which the proposed activity will collaborate with an existing cultural program or will leverage another cultural opportunity. • Likelihood that the proposed activity will increase access to cultural programs or activities, particularly by those who may not otherwise have access such as low income residents, children, or minority groups. C. Tourism As a long standing pillar of Ashland's economy, tourism programs support programs, activities and events that act similarly to more traditional traded sector activity in that dollars from outside the community are brought in and circulated locally to the benefit of our local businesses. Criteria for Evaluation. Grant applications for tourism monies will be evaluated and scored based on the following: • Likelihood that the proposed activity or event will increase hotellmotel occupancy or increase local restaurant and retail business sales. • Likelihood that the proposed activity will increase the total number of jobs in tourism, hotels, restaurants, and retail businesses in Ashland. • Likelihood that the proposed activity will increase hotel/motel occupancy and restaurant/retail business in Ashland in the months of October through April. • Likelihood that the proposed activity will create or support a new non-traditional tourism related event. D. Sus_tainability The goal of the sustainability grants process is to support the exploration and expansion of efforts to ensure that Ashland S an environmentally, economically, and socially resilient community now and into the future. Page 15 of 17 Eligible activities include: 1. Program development, education & training, and outreach related to: local renewable energy supply, production and use; energy efficiency and conservation; water use efficiency and conservation; local food supply; local natural resource or ecology; resource reclamation, reuse and recycling. 2. Programs and activities that assist local businesses in energy, water, waste reductions, and supply chain efficiencies. 3. Programs and activities that support and increase local to local purchasing either by businesses or by retail consumers. Criteria for Evaluation. Grant applications for sustainability monies will be evaluated based on the following: • Likelihood that the proposed activity will contribute to reduced consumption of a critical resource by citizens or businesses in the community. Resources include fuel; electricity, water, land, air, or other natural resources. • Likelihood that the proposed activity will be "transferable." That is, the lessons and experiences gained through the program or activities can be transferred to another resource, organization, or community. • Likelihood that the proposed activity will reduce citizen or business dependence on food, goods or services shipped in from outside the Rogue Valley, i.e. "buy local" efforts. • Degree to which the proposed activity provides quality sustainability related educational opportunities to the community. 11. GRANT APPLICATION AND AWARD REQUIREMENTS Grant applicants and corresponding grant applications must adhere to the following program requirements: 1. Grantee shall be registered as a 501(c) non-profit If your organization is being sponsored by or legally affiliated with a registered non-profit, a letter from that organizations Board of Directors recognizing the affiliation and a copy of the 501 (c) verification of the sponsoring non-profit 2. Grantee shall be a non-government entity. 1 Minimum grant award will be $1,000 per grant category and $5,000 per grant application. 4. Grant award shall be utilized consistent with the associated applicant proposal and shall be primarily oriented to the grantee's Ashland activities and programs. Grant funds may also be utilized for a proportionate share of Grantee's administrative expenses associated with the Ashland activities and programs proposed. 5. An applicant can apply for grant funds from more than one category, however, it is the responsibility of the applicant to specify the categories and funds requested for each category and clearly describe how the proposal meets the criteria for each category. 6. Grantees must submit the application to the City prior to the deadline, which is established each year by the City's Administrative Service Department. Absolute) no late__a_ pplicatlons willbe accepted,, The City is aware that sometimes "life" intervenes; therefore applicants are advised to have a backup plan to ensure that the application is not late. 7. Incomplete applications (see application cover page) will not be forwarded to the grant review committee for consideration 8. Materials submitted beyond those required and listed on the application cover page and application form will not be forwarded to the grant review committee as part of the application packet. III. GRANT REPORTING Grant award recipients shall submit a written report to the City of Ashland at the end of grant period. Report requirements include: Report Content 1. Financial summary of the utilization of grant funds towards the objectives set forth in the grant award application. 2. Statistical summary of the positive economic, cultural or sustainability impacts associated with the utilization of grant funds based on the scoring categories used to make the grant award. Applicants should provide actual data on one or more of the following outcomes: • Number of actual jobs created as a direct result of the City grant. • Number of new business licenses issued as a direct result of the City grant. • Median wage of actual jobs created as a direct result of the City grant. • Number of people who travelled to Ashland from over 50 miles away as a direct result of activities funded by the City's grant- • Number of additional overnight stays in Ashland transient lodging businesses as a direct result of the City's grant. • Number of additional events offered in Ashland as a direct result of the City's grant- • Number of additional people who attended a cultural event in Ashland as a direct result of the City's grant. Page 16 of 17 • Number of additional children, seniors, or low income residents who attended a cultural event in Ashland as a direct result of the City's grant. Amount of conservation or reduction in use of a critical natural resource by Ashland residents, businesses or visitors that is directly attributable to the grant. Document the resource and the evidence that the grant activity resulted in its conservation. 3. Any other program or activity specific data associated with the grant award. Report Submittal 1. End of Grant report shall be submitted to the City Administrator's Office by October 1't following the end of the grant award period (July 1-June 30). 2. Failure to submit an acceptable End of Grant report by the required due date disqualifies the grantee from future grant application eligibility. Page 17 of 17 City Council Study Session March 16, 2015 Page I of 4 MINUTES FOR THE STUDY SESSION ASHLAND CITY COUNCIL Monday, March lb, 2015 Siskiyou Room, 51 Winburn Way Mayor Stromberg called the meeting to order at 5:35 p.m. in the Siskiyou Room. Councilor Lemhouse, Morris, Rosenthal, Voisin, Seffinger, and Marsh were present. 1. Public Input (15 minutes maximum) - (None) 2. Look Ahead review City Administrator Dave Kanner reviewed items on the Look Ahead. 3. WISE Project Update Steve Mason, program manager for Water for Irrigation Streams and Economy (WISE) explained WISE was a new irrigation infrastructure project that would pipe irrigation throughout the Rogue Valley. The Bureau of Reclamation owned half of the 35,000 acres of water including the Talent Irrigation District (TID). Rogue Valley received approximately 30,000-acre feet of water from the Klamath Basin annually. He explained water flow throughout the valley and provided a presentation that included the following: Why Wise? • 2001 Water crisis in Klamath Basin • Protect Agriculture amid urban growth • Protect and restore local streams How WISE? • Proactive approach • Inclusive partnerships • Think big • Long term solutions: Technology, Economies, Regulations WISE Project Goals • Increase summer stream flows • Improve water quality • Improve water temperature • Improved irrigation water reliability • Improved irrigation water availability WISE Project Area Map Possible Sources of Additional Water • Conserved Water: Piped/lined irrigation canals o Increased reservoir storage capacity: Agate • Pumped water o Regional Water Reclamation Facility o Lost Creek Reservoir via Rogue River WISE Piping Layouts Map Specific Irrigation Benefits • Conserved water available for irrigation: 22,297 - 30,998 - 39710 (A/F) Piping open canals would save 31,000-acre feet of water in a normal weather year. City Council Study Session March 16, 2015 Page 2 of 4 • Gravity pressure system Reduced shortages: 77 - 4,674 - 8,019 (A/F) • Extended drought protection More flexible water availability • Minimal moss and algae in system • Greatly reduced canal/pipe maintenance • Hydropower generation Instream Benefits More water instream • Potentially increased flows in tribs 0 2,103 - 9,895 - 20,207 (A/F) o Stored water component in reservoirs o Conserved water from surface rights o Water exchange from reuse component • Elimination of mixed canal and live flows • Significantly improved water quality Ashland Creek had a diversion accessed by the irrigation district. The WISE project would eliminate the need for the diversion and the water would remain in the creek. Water rights would stay the same. Conversion reduction would significantly decrease fertilizers getting into the water. People getting their water from the streams would have new laterals and require easements. Issues • Stormwater management • Perceptions regarding use of Reclaimed effluent • Environmental impacts - vernal pools, wetlands, canal-side vegetation • Shallow wells WISE Project Timeline • 2010 - Complete Prefeasibility Study • 2012 - Begin Cost Benefit Analysis • 2014 - Being FS/EIS • 2015 - Complete CBA 2015 - Construct WISE Pilot Project 2016 - Complete FS/EIS The project would pipe most of the canals coming from Immigrant Creek to Starlite Place. From Starlite Place on there was a chance for Ecoli and unless the City piped, those influences would continue. Mr. Mason confirmed no piping until the power plant. They would line some of the canals coming from the mountain lakes. Piping the water would not affect wildlife. Currently, the canals were dry for six months each year already. Riparian areas and wetlands would be significantly healthier and fish instream would do well. Private water users would not see a change in their water rights. Funding would from the Bureau of Reclamation, WISE, the state, developers and commercial growers. 4. Ashland Conservation Commission - Community Climate and Energy Action Plan proposal Conservation Commissioner Jim McGinnis provided the background on the Council goal for sustainability planning, the Conservation Commission's framework proposal, and Council's earlier request for the Commission to determine the steps needed to develop a climate and energy action plan. City Council Study Session March 16, 2015 Page 3 of 4 The Conservation Commission reviewed several plans from other communities. Highlights from the overall assessment was that both the community and city government were involved in the planning and implementation process that was sponsored and lead by city or county government. They dedicated sustainability staff to lead the process, performed communitywide greenhouse gas assessments and set local emission targets to align with state emission targets. Activities that would fit well in Ashland included community workshops and meetings, education on climate change, goals and strategies for the next 5, 20, and 50 years, and adaptation strategies integrated with mitigation strategies. Conservation Commissioner Brian Sohl addressed the Eugene Climate and Energy Plan adopted by the City of Eugene. The Plan contained four initial goals and targets. Goal 1 was all city operations and facilities were carbon-neutral by 2020. Goal 2 aligned targets for greenhouse gas emissions reductions with the state. The third goal would reduce levels of fossil fuel use 50% by 2030. Goal 4 identified adaptation strategies for climate change. City of Eugene staff identified six action areas that included Buildings and Energy, Food and Agriculture, Land Use and Transportation, Consumption and Waste, Health and Social Services and Urban Natural Resources. Eugene established a Climate and Energy Action Plan Advisory Team and a public engagement process that involved each of the six action areas. Eugene City Council endorsed the plan instead of formally adopting it due to the detail. When the plan went into implementation, the City of Eugene hired another staff person. Commissioner Sohl went on to explain how actions taken by two Eugene citizens group called Our Children's Trust and the Youth Climate Action Now (YouCan) resulted in a climate recovery ordinance passed July 2014. By 2030 the city organization, businesses, and residents living or working in Eugene will collectively reduce fossil fuels 50%. Conservation Commission Chair Marni Koopman addressed next steps, explained the plan needed to be community driven, collaborative, and recommended an oversight group with members from different sectors. The group would deal with greenhouse gas emission, hunger, homelessness, air quality, water shortages, and traffic congestion. Local experts would help set greenhouse gas emissions targets for the community. Another important component of the plan was ongoing outreach. The plan was iterative with reassessments occurring every three years. The planet would already experience 30 years of worsening climate change. Emission cuts would prevent the most serious consequences 50-100 years from now. It would take a long time to change. The Commission estimated the effort would require .5 FTE full time equivalent (FTE) in staff time or the equivalent in contractor assistance during this biennium to manage the development of the plan in year one and implement the plan year two in the spring of 2016. The Conservation Commission would include the senior community for transportation input. The education component would begin with the kick off in 2015. They would use similar tactics used in the economic development strategy to form the committee and contact local experts. If the committee formed through the City, the Mayor would participate in appointing members. The Commission was not sure how the City would handle the consequences for missed goals. Eugene City Council endorsed the plan and adopted the ordinance later. The ordinance had three mandates that provided more flexibility. The departments for the City of Eugene were responsible for meeting goals. City Administrator Dave Kanner explained a contracted .5 FTE was the better option for City staff. Mr. McGinnis noted the STAR framework the Conservation Commission proposed to Council previously and explained the Commission would address the framework during the process. City Council Study Session March 16, 2015 Page 4 of 4 Mr. Kanner would include the plan in the budget. A Council appointed committee made it subject to public meetings laws. Staff could add the committee to the website. The City would form the committee first then hire a contract consultant to facilitate the process. Council and Mayor expressed concern that the plan have actual actions the City and community could initiate and complete within a short period. One comment suggested including the work the Ashland Forest Resiliency (AFR) performed as part of the plan. 5. Discussion of utility billing surcharge for Ashland Forest Resiliency project Councilor Marsh was interested in further developing a utility fee as a long term funding mechanism for the Ashland Forest Resiliency (AFR). There was a significant nexus between watershed health that enabled the municipal water system and a utility fee. The fee would be transparent and dedicated. Increasing property taxes would not allow the City to dedicate specific funds to the watershed since the funds went into the General Fund. There was concern the fee was regressive. Councilor Marsh thought it could be structured to become less regressive. This already occurred in the fee structure for storm water. It would cost an estimated $1.50 per residential household with a gradation that implemented different fee structures for commercial and government. City Administrator Dave Kanner explained a utility tax had the advantage of bringing in revenue from a broader base because everyone depended on the watershed, but not everyone paid property tax. Having a flat fee was regressive. The City could use a methodology where larger water users paid more. It would not be exact. The City could look at meter size or charge a percentage of use but that was difficult to manage. Another possible issue were individuals refusing to pay the surcharge. Was Council willing to shut off someone's water if that happened. If Council approved a utility tax, he recommended it as a watershed maintenance fee instead of a fuels reduction fee. Forest Resource Specialist Chris Chambers addressed other funding options. The US Forest Service hosted Collaborative Forest Restoration Partnerships that affected larger landscapes and consisted of $4,000,000. It would require a mobilized regional effort to apply and was a possibility in the future. The Merkley-Wyden bipartisan bill protected the existing money and did not create a new funding source. The state had the Oregon Watershed Enhancement Board grant that provided a smaller amount, approximately $3,700. Mr. Kanner explained increasing the existing water fund fee 1% would produce $50,000460,000 in revenue. Council wanted to see more funding options, future grants, ways to make the utility fee more progressive, and the possibility of a two-year sunset on the fee with the potential to extend. Other comments preferred a fixed amount on the utility bill and that it applied to everyone. Meeting adjourned at 7:16 p.m. Respectfully submitted, Dana Smith Assistant to the City Recorder CITY OF -AS H LAN DD Council Communication June 2, 2015, Business Meeting Jurisdictional Transfer of Peachey Road from Jackson County to the City of Ashland FROM: Michael R. Faught, Director of Public Works, Public Works, faughtm@ashland.onus SUMMARY Council is asked to approve the jurisdictional transfer of Peachey Road from Jackson County to the City of Ashland. If approved, the maintenance of Peachy Road will become the City's responsibility. BACKGROUND AND POLICY IMPLICATIONS: In April of 2007, Jackson County was awarded a Congestion Mitigation Air Quality (CMAQ) grant by the Rogue Valley Metropolitan Planning Organization to pave Peachey Road from Walker Ave. to Hillview Dr. At that time, a gravel road within the Ashland city limits. Jackson County obtained this grant in order to improve air quality and to build Peachey Road to standards acceptable to the City of Ashland and then transfer jurisdiction from Jackson County to the City of Ashland. Peachey Road is a narrow facility in a well-established and vegetated hillside neighborhood. Early communication between Ashland and Jackson County suggested the street cross section should be 25- feet curb to curb with a 5-foot sidewalk on one side. Jackson County began the design process with the 25-foot cross section. Through the course of design, three well-attended meetings were held with the neighborhood residents. These meetings were also attended by City staff from the Planning and Public Works Departments. Through these meetings, a variable cross section of 18-feet to 22-feet with a 5-foot sidewalk was selected in order to minimize impact to the neighborhood and several well established trees. This final cross section was approved by the City of Ashland through a formal planning approval process. The approved design was then constructed in 2013. City Standards for Street Improvements Jackson County builds roads and streets for a different purpose and to a different standard then does the City of Ashland. The County's goal is to move traffic safely and efficiently in a predominantly rural setting. The City's street standards are aimed at providing a more livable community, to promote alternative modes of travel and to consider these modes on an equal footing with automobile travel. City standards, for instance, require the creation of a park row or planting strip between the curb and sidewalk. The County, on the other hand, requires that sidewalks be adjacent to the curb. Staff believe the benefit to be gained from a well-designed, pedestrian-friendly, urban street outweighs the added responsibility of the infrastructure maintenance. The City has previously and currently maintains sewer, water and storm drain on Peachey. The additional infrastructure maintenance costs are only associated with the pavement. Page 1 of 2 InA CITY OF ASHLAND Although the number is gradually decreasing, there are still a few streets within the City limits that remain under the jurisdiction of Jackson County including: • Tolman Creek Road - south of Siskiyou Boulevard; • Clay Street - between Siskiyou Boulevard and East Main Street; • Paradise Lane - south of Peachy Road; • East Main Street - from Walker Avenue east to Highway 66; and • Crowson Road - between Benson Way and the railroad crossing. Maintenance Requirements By City ordinance sidewalk maintenance is assigned to the adjacent property owners, but the City (or other public agency) is obligated to maintain the concrete curbs, storm system and street surfaces indefinitely. Generally there is little or no maintenance of new infrastructure for the first 10 to 15 years. Concrete curbs and walks generally have a much longer life expectancy than asphalt surfacing which generally needs some sort of remedial action within 20 years. The nature and type of action varies greatly depending upon the type of failure and could be as little as a seal coat or fog seal or in the most extreme condition, a full overlay, maintenance costs run from approximately $3.50 per square yard for a slurry seal to $19 per square yard for an asphalt overlay. COUNCIL GOALS SUPPORTED: Council has asked staff to work with Jackson County on the improvement of County roads within City limits. FISCAL IMPLICATIONS: The transfer means the City will have responsibility for maintaining the roadway in perpetuity. Maintenance costs can vary based on traffic loading and overall usage. The City has a slurry seal program in place to extend the useful life of residential street asphalt. STAFF RECOMMENDATION AND REQUESTED ACTION: Staff recommends approving the jurisdictional transfer of Peachey Road from Jackson County to the City of Ashland. SUGGESTED MOTION: Move to approve a resolution titled "A Resolution Approving the Jurisdictional Transfer of Peachey Road." ATTACHMENTS: Resolution Pale 2 of 2 A& RESOLUTION NO. 2015- A RESOLUTION APPROVING THE JURISDICTIONAL TRANSFER OF PEACHEY ROAD RECITALS: A. Peachey Road has been improved by Jackson County to an agreed upon City of Ashland standard. B. The City is of Ashland is requesting jurisdictional exchange for a portion of Peachey Rd. to better control road improvements within the area. To provide greater City control of improvements to a road within the City's boundary and greater consistency with other City roads, the City of Ashland wishes is to assume responsibility for a portion of Peachey Road, and Jackson County wishes to transfer that portion of the road to the City THE CITY OF ASHLAND RESOLVES AS FOLLOWS: SECTION 1. The City of Ashland is authorized to request and accept from Jackson County jurisdictional transfer of Peachey Road from Walker Avenue to Hillview Drive, as depicted in attached Exhibit A. SECTION 2. This resolution was duly PASSED and ADOPTED this day of , 2015, and takes effect upon signing by the Mayor. This resolution was duly PASSED and ADOPTED this day of 2015, and takes effect upon signing by the Mayor. Barbara Christensen, City Recorder SIGNED and APPROVED this day of )2015. John Stromberg, Mayor Reviewed as to form: David H. Lohman, City Attorney Resolution No. 2013- Page 1 of 1 EXHIBITA CLAYST Q z t: Q J z_ OY AV MADRONE ST Q FREM T ST O 1 `/T z w C~ MO O co fiES OREGON ST z ti Y z w PROSPEC w w a ST z VENTU A N WINDSOR ST CR ELMS ST FIELDER ST Q LILAC CR J tr Q W p ~ a z WOODLAND DR SU SETA z - z O ~ ,+A V EISSENEACJi 1,iY z z o O > Y ~ = J U PON DRROSA N~~P ROSS LN = W VER AST m Q ` 2~P~P PEACHEY RD P ACDHEY Q Q 4 y~G w y °z z F/jy z Y a J Q OO~O O ~f ~ a NEZ AST ham; p Q Q 13RISTOL HOPE ST a ST 4 MOH WK ST TRANSFER w AREA o c SL 7AMAR14CKPL O~ DPAGONFLY_LN_ CITY OF -ASHLAND Council Communication June 2, 2015, Business meeting Second Reading of an Ordinance Amending Chapter 11.28 to Authorize City Council to Establish Presumptive Parking Violation Fines by Resolution and to Clarify How Single Parking Violations Relate to Other Penalties for Parking Violations FROM: David H. Lohman, City Attorney, lohmandnashland.or.us Lee Tuneberg, Administrative Services Director, tuneberl@ashland.onus SUMMARY: This agenda item came before the City Council for its first reading on May 19, 2015. Council approved the proposed Ordinance, with amendments to delete the phrase for each parking violation they receive in that year from proposed Section 11.28.110A(2) and delete the phrase for each violation from the current table immediately following that section. Passage of this proposed ordinance at its second reading would (1) clarify that responsibility for setting parking fines is reserved for the Council; (2) authorize the setting of base (presumptive) parking fines by resolution; and (3) distinguish presumptive fines for parking violations from penalties for multiple parking violations, from enhanced penalties for ignoring parking tickets, and from the current parking fine surcharge. BACKGROUND AND POLICY IMPLICATIONS: The current municipal code sets forth in Sections 11.24.100, 11.28.11 OA and 11.28.120 specific dollar amounts for penalties for multiple parking violations, for enhanced penalties for ignoring parking tickets, and for a parking fine surcharge. Current code also specifically authorizes impoundment, immobilization by parking boot, and towing as means for dealing with parking violations. But current code does not set the amounts for simple, one-time parking violations and does not state who has responsibility for setting those amounts. The current $7 fine for a simple overtime parking violation (to which is added a $4 parking surcharge for parking improvements) apparently was established by a former municipal court judge more than 30 years ago. In order to set the stage for Council consideration of a resolution updating the fines for parking violations, staff recommends the attached ordinance amendment. The proposed ordinance amendment would allow the presumptive fines for parking violations to be set by Council resolution. Including parking fines in the master fee schedule approved by resolution annually would encourage regular review of the appropriateness of the amount established for the presumptive fines. The other parking violation penalties already set by ordinance would not be affected by this amendment. By cross-referencing other relevant AMC provisions on penalties related to parking citations, the proposed amendment would also make clear that those penalties are all independent of the presumptive Page I of 2 ~r, CITY OF -AS H LA N D fines for single parking violations and are subject to their own distinct provisions in the Ashland Municipal Code. The proposed amendment would delete current code language in AMC 11.28.110A imposing a $50 dollar penalty for each violation in excess of five violations in any calendar year. This provision has existed for a number of years but in recent years has not been rigorously observed. At the May 19 meeting, the Council chose to retain the $50 penalty for five parking violations in any calendar year but delete the language imposing the $50 penalty for each parking violation after the fifth one and to reconsider penalties for multiple violations as part of a future comprehensive review of penalties for parking violations. 'The proposed amendment also adds the phrase "in one calendar year" to the table already contained in current AMC 11.28.110A. This addition is to make the table clearly reflect the timeframe set in the immediately preceding text, namely that penalties for multiple violations are based on cumulative violations in each calendar year. Following a future study session on enforcement of parking regulations, staff anticipates proposing to Council further, more extensive changes to AMC chapters 11.24 and 11.28. COUNCIL GOALS SUPPORTED: N/A FISCAL IMPLICATIONS: Passage of the ordinance amendment is likely to result in a modest increase in Ashland Municipal Court revenues from parking fines, although the expected primary benefit will be a reduction in parking violations, especially in the downtown area. STAFF RECOMMENDATION AND REQUESTED ACTION: Staff recommends passage of this ordinance as approved on First Reading. SUGGESTED MOTION: I move approval of the second reading by title only of an ordinance titled, "An Ordinance Amending Chapter 11.28 to Authorize City Council to Establish Presumptive Parking Violation Fines by Resolution." ATTACHMENTS: Proposed Ordinance with Amendment Page 2 of 2 Imo, ORDINANCE NO. AN ORDINANCE AMENDING CHAPTER 11.28 TO AUTHORIZE CITY COUNCIL TO ESTABLISH PRESUMPTIVE PARKING VIOLATION FINES BY RESOLUTION Annotated to show deletions and additions to the code sections being modified. Deletions are bold lined through and additions are bold underlined. WHEREAS, Article 2. Section 1 of the Ashland City Charter provides: Powers of the City. The City shall have all powers which the constitutions, statutes, and common law of the United States and of this State expressly or impliedly grant or allow municipalities, as fully as though this Charter specifically enumerated each of those powers, as well as all powers not inconsistent with the foregoing; and, in addition thereto, shall possess all powers hereinafter specifically granted. All the authority thereof shall have perpetual succession. WHEREAS, penalties for certain cumulative violations of parking-related regulations exist in multiple chapters of the Ashland Municipal Code. WHEREAS, the amounts of fines for one-time parking violations are not mentioned in the Ashland Municipal Code. WHEREAS, the City Council has the authority to determine the amount of a presumptive fine for each type of parking violation and can exercise that authority in an expeditious manner by resolution. THE PEOPLE OF THE CITY OF ASHLAND DO ORDAIN AS FOLLOWS: SECTION 1. Chapter 11.28 Restricted Parking Areas, Section 11.28.080 is hereby amended to read as follows: Section 11.28.080 Parking Violation Prohibition A parking violation is a violation of any parking prohibition, limitation or regulation of the City of Ashland. A vehicle parked in violation of this chapter or Chapter 11.24 shall have a notice of violation attached to the vehicles and the owner or operator of the vehicle shall be subject to the fines and other penalties and surcharl4es provided in Section 1.08.020 11.24.100 and this chapter, and may be subject to the impounding of such vehicle as provided in Chapter 11.36. A person who commits a parking violation may not suffer any disability or legal disadvantage based upon conviction of a crime. Ordinance No. Page 1 of 4 SECTION 2. Chapter 11.28 Restricted Parking Areas, Section 11.28.110 Penalties for Parking Violations; Immobilization, Towing, Show Cause and Warrants is hereby amended to read as follows: Section 11.28.110 Penalties for parking violations;, immobilization, towing, show cause and warrants: A. Fines M Presumptive fines for parking violations shall be established by resolution of the City Council a. Separate from and in addition to other penalties or charges provided herein, a presumptive fine is the fine amount imposed against a person who pleads no contest to or is otherwise found guilty of a violation Fines shall include the original ticketed amount as well as any enhanced penalties and surcharges, including those set forth in Section 1124100 and Section 11.28.120. In addition, a person who commits three or four parking violations in any calendar year shall pay an additional fine of $25, and a person who commits five or more parking violations in any calendar year shall pay an additional fine of $50. for Multiple Violation Penalties* • violations Additional Penalty 3 violations $25.00 4 violations in one calendar ear $25.00 5 or more violations in one calendar year $50.00 r°e'' - iol *This table does not include the presumptive fines, enhanced penalties, surcharges, or other fees authorized under this chapter. B. Immobilizer (boot) Installation and /or Towing. (1) When a driver, registered owner, or person in charge of a motor vehicle has either (1) five or more outstanding unpaid City of Ashland parking violations on any number of motor vehicles, or (2) a City of Ashland parking violation, or any number of such violations, with a total unpaid balance that exceeds $250, regardless of the number of motor vehicles involved, then any police or parking enforcement officer, or contracted parking enforcement provider of the City is authorized, directed and empowered to immobilize such a motor vehicle or vehicles found upon a public street or city off-street parking lot by installing on or attaching to the motor vehicle a device designed to restrict the normal movement of the vehicle. In the alternative, or in addition to immobilization, after 24 hours has elapsed, any police or parking enforcement officer or contracted parking enforcement provider of the City is authorized, directed and empowered to order such vehicle towed, by a licensed tow company under contract with the City or the City' s contracted parking enforcement service provider, as applicable. Ordinance No. Page 2 of 4 (2) For purposes of this section, bail or fine shall be outstanding on a citation when the citation is issued and shall remain outstanding until the bail is posted or the fine is paid. (3) Ten days before immobilizing or towing a vehicle according to the provisions of this section, the City, or the City' s contracted parking enforcement service provider shall place a notice on the vehicle or mail a notice by certified mail, return receipt requested, to the registered owner of such vehicle as shown by the records of the Oregon Motor Vehicles Division notifying the owner that the motor vehicle or vehicles may be immobilized and/or towed ten days after the date of mailing the notice herein for failure to pay outstanding parking bail or fines. (4) If the vehicle is so immobilized, the person who installs or attaches the device shall conspicuously affix to the vehicle a written notice on a form approved by the city, advising the owner, driver, or person in charge of the vehicle that it has been immobilized pursuant to this section and that release of the vehicle may be obtained upon full payment of the outstanding balance owed to the contracted parking enforcement service provider. The notice shall also specify that the vehicle is subject to tow. (5) In the event the vehicle is towed, the person who orders the tow, shall send by certified mail, return receipt requested, a notice advising the registered owner of the vehicle that it has been towed pursuant to this section and that release of the vehicle may be obtained upon receipt by the towing company of full payment of the outstanding balance owed. (6) A vehicle towed and impounded pursuant to this section shall be held at the expense of the owner or person entitled to possession of the vehicle. Personnel, equipment and facilities of private tow companies under contract with the City or the contracted parking enforcement service provider may be used for the removal and storage of the vehicle. C. Warning Letter, Show Cause, and Warrants. (1) Warning Letter. The Ashland Municipal Court may choose to send a warning letter by first class mail informing the defendant they have outstanding parking tickets and that their attendance is necessary at a preliminary hearing before issuing a show cause order and warrant. (2) Show Cause. The Ashland Municipal Court may issue an order that requires the defendant to appear and show cause why the defendant should not be held in contempt of court, including contempt for failure to appear as ordered or failure to comply. The show cause order shall be mailed to the defendant by certified mail, return receipt requested, no less than ten days prior to the appearance date; alternatively service may be made by any other recognized method, such as personal service according to the same timeframe. (3) Warrant. If the defendant is served and fails to appear at the time specified in the show cause order, the court may issue an arrest warrant for the defendant for the purpose of bringing the defendant before the court. SECTION 3. Savings. Notwithstanding this amendment/repeal, the City ordinances in existence at the time any criminal or civil enforcement actions were commenced, shall remain valid and in full force and effect for purposes of all cases filed or commenced during the times said Ordinance No. Page 3 of 4 ordinances(s) or portions thereof were operative. This section simply clarifies the existing situation that nothing in this Ordinance affects the validity of prosecutions commenced and continued under the laws in effect at the time the matters were originally filed. SECTION 4. Severability. The sections, subsections, paragraphs and clauses of this ordinance are severable. The invalidity of one section, subsection, paragraph, or clause shall not affect the validity of the remaining sections, subsections, paragraphs and clauses. SECTION 5. Codification. Provisions of this Ordinance shall be incorporated in the City Code, and the word "ordinance" may be changed to "code", "article", "section", or another word, and the sections of this Ordinance may be renumbered or re-lettered, provided however, that any Whereas clauses and boilerplate provisions, i.e., Sections 3-5 need not be codified, and the City Recorder is authorized to correct any cross-references and any typographical errors. The foregoing ordinance was first read by title only in accordance with Article X, Section 2(C) of the City Charter on the day of 2015, and duly PASSED and ADOPTED this day of 2015. Barbara M. Christensen, City Recorder SIGNED and APPROVED this day of , 2015. John Stromberg, Mayor Reviewed as to form: David H. Lohman, City Attorney Ordinance No. Page 4 of 4